First-of-Its Kind Guideline on Lipid Monitoring in Endocrine Diseases

Endocrine diseases of any type — not just diabetes — can represent a cardiovascular risk and patients with those disorders should be screened for high cholesterol, according to a new clinical practice guideline from the Endocrine Society.

"The simple recommendation to check a lipid panel in patients with endocrine diseases and calculate cardiovascular risk may be practice changing because that is not done routinely," Connie Newman, MD, chair of the Endocrine Society committee that developed the guideline, told Medscape Medical News.

"Usually the focus is on assessment and treatment of the endocrine disease, rather than on assessment and treatment of atherosclerotic cardiovascular disease risk," said Newman, an adjunct professor of medicine in the Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, at the New York University Grossman School of Medicine in New York City.

Whereas diabetes, well-known for its increased cardiovascular risk profile, is commonly addressed in other cardiovascular and cholesterol practice management guidelines, the array of other endocrine diseases are not typically included.

"This guideline is the first of its kind," Newman said.

"The Endocrine Society has not previously issued a guideline on lipid management in endocrine disorders (and) other organizations have not written guidelines on this topic."

"Rather, guidelines have been written on cholesterol management, but these do not describe cholesterol management in patients with endocrine diseases such as thyroid disease (hypothyroidism and hyperthyroidism), Cushing's syndrome, acromegaly, growth hormone deficiency, menopause, male hypogonadism, and obesity," she noted.

But these conditions carry a host of cardiovascular risk factors that may require careful monitoring and management.

"Although endocrine hormones, such as thyroid hormone, cortisol, estrogen, testosterone, growth hormone, and insulin, affect pathways for lipid metabolism, physicians lack guidance on lipid abnormalities, cardiovascular risk, and treatment to reduce lipids and cardiovascular risk in patients with endocrine diseases," she explained.

Vinaya Simha, MD, an internal medicine specialist at the Mayo Clinic, in Rochester, Minnesota, agrees that the guideline is notable in addressing an unmet need.

Recommendations that stand out to Simha include the suggestion of adding eicosapentaenoic acid (EPA) ethyl ester to reduce the risk of cardiovascular disease in adults with diabetes or atherosclerotic cardiovascular disease who have elevated triglyceride levels despite statin treatment.

James L. Rosenzweig, MD, an endocrinologist at Hebrew SeniorLife, in Boston, Massachusetts, agrees this is an important addition to an area that needs more guidance.

"Many of these clinical situations can exacerbate dyslipidemia and some also increase the cardiovascular risk to a greater extent in combination with elevated cholesterol and/or triglycerides," he told Medscape Medical News.

"In many cases, treatment of the underlying disorder appropriately can have an important impact in resolving the lipid disorder. In others, more aggressive pharmacological treatment is indicated," he said.

"I think that this will be a valuable resource, especially for endocrinologists, but it can be used as well by providers in other disciplines."

Key Recommendations for Different Endocrine Conditions

The guideline, published in the Journal of Clinical Endocrinology & Metabolism, details those risks and provides evidence-based recommendations on their management and treatment.

Key recommendations include:

Obtain a lipid panel and evaluate cardiovascular risk factors in all adults with endocrine disorders.
In patients with type 2 diabetes and risk factors for cardiovascular disease, start statin therapy in addition to lifestyle modification to reduce cardiovascular risk. "This could mean earlier treatment because other guidelines recommend consideration of therapy at age 40," Newman said.
Statin therapy is also recommended for adults over 40 with type 1 diabetes with a duration of diabetes of more than 20 years and/or microvascular complications, regardless of their cardiovascular risk score. "This means earlier treatment of patients with type 1 diabetes with statins in order to reduce cardiovascular disease risk," Newman noted.
In patients with hyperlipidemia, rule out hypothyroidism as the cause before treating with lipid-lowering medications. And among patients who are found to have hypothyroidism, re-evaluate the lipid profile when the patient has thyroid hormone levels in the normal range.
Adults with persistent endogenous Cushing's syndrome should have their lipid profile monitored. Statin therapy should be considered in addition to lifestyle modifications, irrespective of the cardiovascular risk score.
In post-menopausal women, high cholesterol or triglycerides should be treated with statins rather than hormone therapy.
Evaluate and treat lipids and other cardiovascular risk factors in women who enter menopause early (before the age of 40-45 years).

Nice Summary of 'Risk-Enhancing' Endocrine Disorders

Simha told Medscape Medical News that the new guideline is "probably the first comprehensive statement addressing lipid treatment in patients with a broad range of endocrine disorders besides diabetes."

"Most of the treatment recommendations are congruent with other current guidelines such as the American College of Cardiology (ACC)/American Heart Association (AHA) [guidelines], but there is specific mention of which endocrine disorders represent enhanced cardiovascular risk," she explained.

The new recommendations are notable for including "a nice summary of how different endocrine disorders affect lipid values, and also which endocrine disorders need to be considered as 'risk enhancing factors'," Simha noted.

"The use of EPA in patients with hypertriglyceridemia is novel compared to the ACC/AHA recommendation. This reflects new data which is now available," she added.

The American Association of Clinical Endocrinologists also just issued a new algorithm on lipid management and prevention of cardiovascular disease in which treatment of hypertriglyceridemia is emphasized.

In addition, the new Endocrine Society guideline "also mentions an LDL treatment threshold of 70 mg/dL, and 55 mg/dL in some patient categories, which previous guidelines have not," Simha noted.

Overall, Newman added that the goal of the guideline is to increase awareness of key issues with endocrine diseases that may not necessarily be on clinicians' radars.

"We hope that it will make a lipid panel and cardiovascular risk evaluation routine in adults with endocrine diseases and cause a greater focus on therapies to reduce heart disease and stroke," she said.

Newman, Simha, and Rosenzweig have reported no relevant financial relationships.

J Clin Endocrinol Metab. 2020;105:dgaa674Link. Full text

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