Hypercholesterolaemia

Secondary Causes

Most Common: Excessive alcohol intake (↑ TGs); Diabetes

Other Causes

• Hypothyroidism

• Nephrotic syndrome

• Cholestatic or chronic liver disease

• Obesity

Pharm Management

1st Line

• High-intensity statins:

  • Atorvastatin 40–80mg OD

  • Rosuvastatin 20–40mg OD

• Statins remain the cornerstone for LDL-C reduction and cardiovascular risk reduction​

2nd Line

• Ezetimibe 10mg OD: Reduces cholesterol absorption; used as monotherapy if statins are not tolerated​

• Fibrates:

  • Stimulate PPAR-alpha to reduce TGs and mildly reduce LDL while increasing HDL

  • Fenofibrate 145mg OD: Preferred fibrate​

  • Consider in combination with statins if TG >4mmol/L, especially if HDL <1mmol/L

  • Dose reduction required for eGFR 20–60 (96mg OD) and eGFR 10–20 (48mg OD)

  • Also used in diabetic retinopathy treatment​

• Bile Acid Binding Resins (e.g., cholestyramine 4–8g OD):

  • Effective for cholesterol reduction but avoid in elevated TGs as they increase TG levels

Note: TGs >10mmol/L significantly increase the risk of pancreatitis; fibrates or fish oils are preferred for initial management of severe hypertriglyceridaemia​

Non-Pharm Management

• Increase intake of plant sterol-enriched foods (milk, margarine, cheese): Can reduce LDL-C by ~15%​

• Increase soluble fibre intake (e.g., oats, legumes)

• Reduce saturated fats (and avoid trans fats)

• Replace saturated fats with monounsaturated and polyunsaturated fats (e.g., nuts, olive oil, fish)

Notes

• TG-lowering focus: Severe hypertriglyceridaemia (>10mmol/L) warrants urgent management to prevent pancreatitis

• Combination therapy: Statins can be safely combined with ezetimibe or fibrates (except gemfibrozil, due to rhabdomyolysis risk)​