The Treatment of Disorders of Lipid Metabolism.

BACKGROUND: Disorders of lipid metabolism are very common. They play an important role in the pathogenesis of atherosclerosis and can be effectively treated by lifestyle changes and drugs.

METHODS: This review is based on pertinent literature retrieved by a selective search.

RESULTS: The main disorders of lipid metabolism are LDL-hypercholesterolemia, hypertriglyceridemia, mixed hyperlipoproteinemia, and low HDL cholesterol. The lipoprotein(a) level can also be elevated either in isolation or in combination with other disorders of lipid metabolism. According to the current European recommendations, an LDL-cholesterol target value should be defined on the basis of the overall cardiovascular risk. If this risk is very high, as in patients with documented atherosclerosis, the target value should be set at <70 mg/dL (<1.8 mmol/L). If the risk is lower, higher target values can be set: <100 mg/dL (<2.6 mmol/L) or <115 mg/dL (<3.0 mmol/L). Lifestyle changes are an effective treatment mainly for patients with hypertriglyceridemia and mixed disorders of lipid metabolism. Lowering the LDL-cholesterol concentration with statins is by far the most important type of pharmacotherapy. Patients who cannot tolerate statins or whose cholesterol level is not adequately lowered can be given ezetimibe instead. PCSK9 antibodies have been available since the autumn of 2015; they can apparently lower the LDL-cholesterol level by more than 50% , but no endpoint trials have yet been reported. At present, they should only be given to carefully selected patients. Fibrates and omega-3 fatty acids have been found to prevent cardiovascular events in monotherapy trials but yield no added benefit when given together with statins. The design of these trials was faulty, however, and the utility of such combinations in patients with mixed disorders of lipid metabolism or hypertriglyceridemia cannot yet be definitively assessed.

CONCLUSION: There is a causal relationship between hypercholesterolemia and the risk of vascular and cardiovascular events. A reduction of LDL cholesterol lessens the risk of cardiovascular events.