2024 The Royal College of Physicians of Thailand (RCPT) clinical practice guidelines on management of dyslipidemia for atherosclerotic cardiovascular disease prevention
Article Category: Practice guidelines
Published Online: Dec 16, 2024
Page range: 246 - 267
DOI: https://doi.org/10.2478/abm-2024-0033
Keywords
© 2024 Praween Lolekha et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
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Classification of statins by LDL-C reduction efficacy
| Reduces LDL-C by >50% before treatment | Reduces LDL-C by approximately 30%–50% before treatment | Reduces LDL-C by <30% before treatment |
|
Atorvastatin 40–80 mg/d Rosuvastatin 20 mg/d |
Atorvastatin 10–20 mg/d Fluvastatin 80 mg/d Pitavastatin 1–4 mg/d Pravastatin 40 mg/d Rosuvastatin 5–10 mg/d Simvastatin 20–40 mg/d |
Fluvastatin 20–40 mg/d Pravastatin 10–20 mg/d Simvastatin 10 mg/d |
Behavior and risk factors associated with cardiovascular disease from atherosclerosis
|
Smoking Poor nutrition Physical inactivity |
Hypertension Dyslipidemia Prediabetes/diabetes Obesity/visceral obesity Sleep apnea Hypercoagulable state/hemoconcentration Inflammation marker Proteinuria Left ventricular hypertrophy |
Older age Male sex Family history of premature atherosclerosis Poor socioeconomic status |
Classes of recommendations
| I | The evidence and/or consensus suggest that the treatment or measure is beneficial, useful, and effective for patients. |
| IIa | The evidence or opinion tends to support the idea that the measure is beneficial and potentially effective for patients. |
| IIb | The evidence or opinion regarding the benefit and potential effectiveness of the measure is still unclear. |
| III | The evidence or overall consensus suggests that the treatment or measure is not useful, not effective, and in some cases, may be harmful to patients. |
Medications for dyslipidemia treatment
| Statins |
Atorvastatin 10–80 mg/d Fluvastatin 20–80 mg/d Lovastatin 10–80 mg/d Pitavastatin 1–4 mg/d Pravastatin 10–80 mg/d Rosuvastatin 5–20 mg/d Simvastatin 10–40 mg/d |
Lower plasma LDL-C levels by 21%–55% Increases plasma HDL-C by 2%–10% Lower plasma TG levels by 6%–30% |
Risk of muscle symptoms, hepatitis, and increased diabetes risk. Simvastatin and atorvastatin may interact with CYP450 inhibitors. Maximum dose of simvastatin is 40 mg/d; avoid using 80 mg/d. |
| Ezetimibe (cholesterol absorption inhibitor) | Ezetimibe 10 mg/d (Take once daily) | Lowers plasma LDL-C by 10%–18% and apoB by 11%–16%. Combined with statins, reduces LDL-C by an additional 25% [ |
May cause muscle symptoms. |
| Bile acid sequestrants | Cholestyramine 8–16 mg/d | Lowers plasma LDL-C levels by 15%–25% |
Not recommended for use in mixed dyslipidemia as it can increase plasma TG levels. Can cause gastrointestinal symptoms. Reduces the absorption of fat-soluble vitamins. Interferes with the absorption of other medications, including statins, so other medications should be taken 1 h before or 4 h after cholestyramine. |
| PCSK9 monoclonal antibody |
Alirocumab 75 mg or 150 mg SC every 2 weeks, or 300 mg every 4 weeks Evolocumab 140 mg SC every 2 weeks, or 420 mg every 4 weeks. |
Lowers plasma LDL-C levels by 50%–60% |
Injection site reaction, flu-like symptoms. Keep in a cooler device with a cold pack to maintain drug efficacy during transportation in tropical climates [ |
| PCSK9 siRNA | Inclisiran 248 mg SC at 0, 3, then every 6 months | Lowers plasma LDL-C levels by 40%–60% |
Injection site reaction, headache, bronchitis. |
| Bempedoic acid | 180 mg/d | Lowers plasma LDL-C levels by 23% when used as monotherapy, 36% when combined with ezetimibe, and 12.6%–16.5% when combined with statins |
Gout, flu-like symptoms, tendon injury. |
| Fibrates |
Fenofibrate 100, 300 mg/d Micronized fenofibrate 200 mg/d Microcoated fenofibrate 160 mg/d Nanoparticle fenofibrate 145 mg/d Fenofibric acid (delayed release) 135 mg/d Fenofibric acid 145, 160, 200 mg/d Gemfibrozil 600–1,200 mg/d Pemafibrate 0.2–0.4 mg/d |
Lower plasma TG levels by 20%–35% Increases plasma HDL-C by 6%–18% |
Gemfibrozil: not recommended with statins. Fenofibrate: take with food to enhance absorption. Use fibrates with caution in CKD patients. |
| Omega-3 fatty acids |
EPA/DHA 2–4 g/d Pure EPA 2–4 g/d |
Lower plasma TG by 20%–50% |
Increased bleeding risk. |
The strength of recommendations in the context of clinical practice in Thailand
| ++ | “Strongly recommend” indicates a high level of confidence in the recommendation, as the measure is highly beneficial to patients and cost-effective. |
| + | “Recommend” indicates a moderate level of confidence in the recommendation, as the measure may be beneficial to patients and may be cost-effective in specific situations (it may be optional depending on the circumstances and appropriateness). |
| +/− | “Neither recommend nor against” indicates an uncertain level of confidence in providing the recommendation, as there is insufficient evidence to support or oppose the measure. It may or may not be beneficial to patients and may not be cost-effective, but it does not increase harm to patients. Therefore, the decision to proceed depends on other factors (it may or may not be done). |
| − | “Not recommend” indicates a moderate level of confidence in advising against the measure, as it is not beneficial to patients and is not cost-effective unless necessary. |
| −− | “Strongly not recommend/against” indicates a high level of confidence in advising against the measure, as it may cause harm or pose a danger to patients. |
Maximum recommended doses of lipid-lowering drugs in CKD patients
| Atorvastatin | 40–80 | 40–80 | 20–40 | 20 |
| Fluvastatin | 80 | 80 | No data | 80 |
| Pitavastatin | 4 | 4 | 2 | No data |
| Pravastatin | 40 | 40 | 20 | 20 |
| Rosuvastatin | 40 | 20 | 10 | 5 |
| Simvastatin | 40 | 40 | 20–40 | 20 |
| Simvastatin/ezetimibe | 40/10 | 40/10 | 20/10 | 20/10 |
| Cholestyramine | 16 | 16 | 16 | 16 |
| Fenofibrate | 300 | 100 | Not recommended | Not recommended |
| Fenofibrate (micronized form) | 200 | 100 | Not recommended | Not recommended |
| Fenofibrate (micronized and microcoated form) | 160 | 80 | Not recommended | Not recommended |
| Fenofibrate (nano-technology form) | 145 | 72.5 | Not recommended | Not recommended |
| Gemfibrozil | 1,200 | 1,200 | 600 | 600 |
| Pemafibrate | 0.4 | 0.4 | 0.2 | No data |
| Ezetimibe | 10 | 10 | 10 | 10 |
| Niacin | 2,000 | 2,000 | 1,000 | No data |
| Omega-3 fatty acids (EPA/DHA) | 4,000 | 4,000 | 4,000 | 4,000 |
| Pure EPA | 4,000 | 4,000 | 4,000 | 4,000 |
| Alirocumab | 75–150 | 75–150 | 75–150 | 75–150 |
| Evolocumab | 140–420 | 140–420 | 140–420 | 140–420 |
| Inclisiran | 284 | 284 | 284 | 284 |
Diagnostic criteria for albumin in urine
| A1 | <30 | <3 | <30 | Normal or slightly increased |
| A2 | 30–300 | 3–30 | 30–300 | Moderately increased |
| A3 | >300 | >30 | >300 | Severely increased |
Stages of CKD
| Stage 1 | >90 | Normal or high |
| Stage 2 | 60–89 | Mild decrease |
| Stage 3a | 45–59 | Mild to moderate decrease |
| Stage 3b | 30–44 | Moderate to severe decrease |
| Stage 4 | 15–29 | Severe decrease |
| Stage 5 | <15 | End-stage kidney failure |
Levels of evidence
| A | Data derived from multiple randomized clinical trials or meta-analyses. |
| B | Data derived from a single randomized clinical trial or large non-randomized studies. |
| C | Consensus of the experts and/or small studies, retrospective studies, and registries |