How are LDL-C and HDL-C levels managed in metabolic syndrome?

Updated: Mar 30, 2020
  • Author: Stanley S Wang, JD, MD, MPH; Chief Editor: Yasmine S Ali, MD, MSCI, FACC, FACP  more...
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Management of elevated LDL-C includes consideration of all statins (3-hydroxy-3-methylglutaryl coenzyme A [HMG-CoA] reductase inhibitors) at all indicated ranges, as there are several formulations available with different doses and potencies. Statins affect the lipid profile favorably and provide possible pleiotropic benefits. [95] The choice of drug and dose should be individualized to the patient and titrated to achieve guideline-recommended goals. As a class, statins are pregnancy category "X" (contraindicated; benefit does not outweigh risk).

Management of reduced HDL-C remains controversial, but starts with diet/exercise modifications and may include niacin. Certain statins (such as rosuvastatin) may help, but this is not yet a widely accepted indication.

Cholesteryl ester transfer protein (CETP) inhibitors have been studied as potential agents to raise HDL-C levels in a clinically meaningful manner. Though torcetrapib increased HDL-C levels, it failed to improve clinical outcomes in the ILLUSTRATE (Investigation of Lipid level Management Using Coronary Ultrasound To Assess Reduction of Atherosclerosis by CETP Inhibition and HDL Elevation) trial. [96] Another CETP inhibitor, anacetrapib, remains in development, and the ongoing DEFINE (Determining the Efficacy and Tolerability of CETP Inhibition with Anacetrapib) trial is expected to shed light on this agent’s potential for reducing clinical cardiovascular events. [97]

Fibrate therapy may serve as an important adjunct in overweight patients with elevated triglyceride and low HDL-C levels (a combination known as atherogenic dyslipidemia). [98]

Niacin raises low HDL-C levels and reduces cardiovascular events but may exacerbate hyperglycemia, especially in high doses (>1500 mg/day), so careful monitoring is recommended. [99]

The latest cholesterol guidelines from the American College of Cardiology emphasize the use of statins over nonstatin therapies, and recommend re-emphasis on adherence to statin and lifestyle therapies before resorting to nonstatin therapies. [100]

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