MANAGEMENT OF COMBINED (MIXED) HYPERLIPIDAEMIA

Initial treatment is by control of overweight, correction of underlying causes and a lipid-lowering diet.

ACTION LIMITS

Plasma cholesterol 5.2-7.8 mmol/l 200-300 mg/dl

LDL cholesterol 3.5-5.5 mmol/l 135-215 mg/dl

Plasma triglyceride 2.3-4.6 mmol/l 200-400 mg/dl

• CONSERVATIVE MEASURES
  
  • The condition most often responds to vigorous, persistent, conservative care.
  • Emphasise correction of overweight, restraint with alcohol, compliance with diet.

• DRUGS
  
  • Consider for patients with coronary disease or those at very high global risk.
  • Fibrates, nicotinic acid or statins are often effective. Statins have greatest ability to lower LDL cholesterol.
  • Fibrates and nicotinic acid are most potent in lowering triglyceride and raising HDL cholesterol. Empirical trial may be needed.

• RETESTING
  
  • If the patient is at high global risk, regular follow-up is recommended. Retest 2- to 3-monthly, increasing to annually.

ACTION LIMITS

Plasma cholesterol <7.8 mmol/l <300 mg/dl

LDL cholesterol <5.5 mmol/l <215 mg/dl

Plasma triglyceride <4.6 mmol/l <400 mg/dl

• CONSERVATIVE MEASURES
  
  • This condition is very rare.
  • As many patients have major genetic hyperlipidaemia, especially remnant hyperlipidaemia, investigate for such disorders or refer to a specialist before initiating treatment.
  • Conservative measures are sometimes effective.

• DRUGS
  
  • Required for most patients with remnant hyperlipidaemia for which fibrates are very effective. Options are nicotinic acid or statin.
  • For other unresponsive patients with coronary disease or at high global risk, fibrates, nicotinic acid or statins are often effective.
  • Statins have greatest ability to lower LDL cholesterol; fibrates and nicotinic acid are most potent in lowering triglyceride and raising HDL cholesterol.
  • Empirical trial may be needed.

• RETESTING
  
  • Retest 2-monthly, increasing to 6-monthly.

• Ensure that blood samples were taken while the patient was fasting (14h).

If the patient has familial combined hyperlipidaemia, diet alone may be insufficient to lower the risk of CHD.