By: Maged Taman
The National Cholesterol Education Program (Adult Treatment Program [ATP] III) guidelines, published in 2001, identified the following HDL cholesterol levels as high risk:
1- HDL less than 40 mg/dL (1.0 mmol/L)
2- For patients with the metabolic syndrome (insulin resistance syndrome or syndrome X), gender adjusted HDL-cholesterol levels of less than 40 mg/dL in men and 50 mg/dL in women.
ATP III recommends the following approach to the management of patients with low HDL :
The primary target of therapy is LDL cholesterol; this goal should be reached before treating low HDL cholesterol.
1- For all patients: intensify weight management, increase physical activity, and encourage smoking cessation.
2- When a low HDL is associated with high triglycerides (200 to 499 mg/dL [2.3 to 5.6 mmol/dL]), first achieve non-HDL goals. Thus the goal of LDL according to patient risk of cardiovascular disease.
3- If triglycerides are <200 name="32">Exercise
1- weight loss (in overweight subjects)
2- smoking cessation
3- substitution of monounsaturated for saturated fatty acids
4- Avoiding if possible medications that lower HDL-cholesterol (beta blockers and androgens)
5- Lipid lowering drugs: most effective nicotinc acid, fibrate and statin in this order. However the choice depend in the LDL levels and trigylcerides. Thus a statin is used if LDL is elevated and fibrate is used if triglyerides are elevated while in isolated low HDL nicotinc acid is the drug of choice.
Lipid lowering in Common clinical scenarios:
1- Patient with elevated LDL, normal triglycerides and low HDL: use statin to acheive LDL goal, HDL may go up some highest with crestor 10%. Nicotinc acid may be added if HDL is still low. Statin and Nicotinc acid combination cause slight increase in myopathy over statin alone.
2- If elevated LDL is accompanied with high triglycerides (200-499 mg/dl) and low HDL: statin is first started according to targeted cholesterol level, then if targets for triglycerides not achieved add fibrates. The lesser myopathy would be expected with combination of paravastatin and Fenofibrate (Tricor).
3- LDL is not elevated while triglyceride is elevated (200-499 mg/dl) with or without low HDL: Fibrate is the lipid lowering agent of choice in patients with CAD, strong family history of CAD or multiple risk factors for CAD.
4- LDL is minimally elevated while triglycerides is elevated (200-499 mg/dl) and low HDL: Fibrate is used for its main effect in triglycerides in this case and HDL. It may as well bring LDL to target. If still some elevation of LDL a statin can be added. Attentively, Ezetimibe or Bile acid sequestrant are used for statin intolerant patients.
5- Very high triglycerides (> 500 mg/dl): should be treaterd first and quickly by treating the cause as high blood sugar, stopping alcohol or drug like estrogen or tamoxifen. Meantime low fat diet and a fibrate shoud be started. Nicotnic acid may need to be added with good attention to potential rise of blood glucose. After triglyerides are lowered to less than 500 mg/dl and the risk of pancreatitis is prevented a LDL level should be addressed.
6- Isolated low HDL in high risk patients: Nicotinc acid is the drug of first choice. It raises HDL by about 30% , if goal not achieved adding fibrate like gemfibrozil may increase HDL by 45%. For patients who can not tolerate nictoinc acid gemfibrozil can be use alone. Statin like rosuvastatin (crestor) raises HDL by 10% can be considered as an add on to fenofibrate rather than gemfibrozil to minimize risk of myopathy.
