Treatment Guidelines for Dyslipidemia in Special Populations: From Children to Comorbidities

How should lipid-lowering drugs be used for children and adolescents with dyslipidemia?

Currently, the recommended first-line treatment for adolescents with hypercholesterolemia is bile acid sequestrants. The dosage should be individualized, generally starting with a low dose and gradually increasing the dosage to achieve the desired lipid level. Commonly used drugs are cholestyramine and colestipol. Niacin has good lipid-lowering effects and is also used to treat children and adolescents with dyslipidemia. In adolescents with familial hypercholesterolemia, short-term use is safe and effective, with no significant side effects reported. However, the safety of this class of drugs in adolescents and their long-term use is not yet confirmed by objective data. Therefore, most people advocate caution in their use, only for those with poor response to bile acid sequestrants. Experience with statins in children and adolescents is still insufficient and needs to be gradually accumulated.

How should lipid-lowering drugs be chosen for patients with dyslipidemia and hypertension?

Dyslipidemia and hypertension are often two co-occurring diseases. Both dyslipidemia and hypertension are risk factors for coronary heart disease. When both blood pressure and lipid levels coexist, the incidence of coronary heart disease is significantly higher than when only one condition is present, indicating a synergistic effect. Therefore, aggressive treatment for these patients is necessary to lower both blood pressure and lipid levels. For information on blood pressure treatment, please refer to Question 62 in Part I on hypertension. When treating patients with dyslipidemia and hypertension with medication, the appropriate lipid-lowering drugs should be selected based on the type and severity of the dyslipidemia.

① For patients with primarily elevated serum total cholesterol, the following drugs can be used: statins and bile acid sequestrants.

② For patients with primarily elevated triglycerides, the following drugs can be used: fibrates and niacin. ③ For patients with mixed dyslipidemia, the above two types of lipid-lowering drugs can be used in combination.

Which antihypertensive drugs are unsuitable for patients with dyslipidemia and hypertension? The antihypertensive drugs unsuitable for patients with dyslipidemia and hypertension are the same as those unsuitable for patients with hypertension and dyslipidemia.

How should patients with dyslipidemia and diabetes choose their medications?

Dyslipidemia can lead to diabetes. Clinically, it's common to see patients with both elevated blood sugar and blood lipids. This can be due to two possibilities:

First, dyslipidemia may have occurred first, leading to elevated blood sugar. This is because dyslipidemia can cause lipotoxicity, impairing the function of pancreatic beta cells in secreting insulin or weakening insulin's effect (insulin resistance).

Second, diabetes may have occurred first, causing elevated blood sugar and subsequently elevated blood lipids, which is secondary dyslipidemia. However, it's difficult to determine the order of occurrence clinically, but drug treatment must be administered simultaneously, i.e., lipid-lowering drugs and hypoglycemic drugs used together.

① Lipid-lowering drugs: The primary treatment target is low-density lipoprotein cholesterol (LDL-C). Statins are the first-line treatment. Bile acid sequestrants can be used if statins are contraindicated. Fibrates can be used if triglyceride levels are between 2.26 and 5.64 mmol/L. Fibrates or niacin can be used if high-density lipoprotein cholesterol (HDL-C) is below 1.00 mmol/L. ② Hypoglycemic drugs: Gliclazide, glipizide, metformin, acarbose, etc., can be selected. These drugs can directly regulate the levels of cholesterol, triglycerides, and high-density lipoprotein cholesterol, which helps reduce the risk of coronary heart disease in diabetic patients.

Why do diabetic patients need more aggressive lipid-lowering treatment? Why do so many diabetic patients have abnormal blood lipids? This is because glucose metabolism and lipid metabolism in the human body are closely related. When glucose metabolism is disrupted, it affects the normal synthesis and breakdown of lipids in the body, increasing lipid synthesis and slowing down breakdown. This ultimately leads to abnormal blood lipids; one-third to one-half of diabetic patients have elevated TC, TG, LDL-C, and decreased HDL-C, indicating lipid metabolism disorders. Lipid metabolism disorders easily lead to arteriosclerosis, a major risk factor for cardiovascular and cerebrovascular diseases, which are the leading causes of death in type 2 diabetic patients. Therefore, diabetic patients must actively undergo lipid-lowering treatment.

How to prevent and treat gout complicated by dyslipidemia? The number of gout patients with dyslipidemia is significantly higher, indicating that gout is easily affected by a high-fat diet, especially closely related to obesity. 75%–84% of gout patients also have hypertriglyceridemia. Studies show that the degree of triglyceride elevation is positively correlated with serum uric acid levels. The incidence of angina and myocardial infarction is high in gout patients, also due to dyslipidemia and arteriosclerosis. Therefore, gout patients must devote significantly more effort than others to preventing dyslipidemia, especially hypertriglyceridemia.

How to prevent it? ① Choose lipid-lowering drugs according to the type of dyslipidemia. Note that gout patients should not use high-dose niacin-like drugs; ② Prevent obesity; ③ Reduce salt intake; ④ Avoid unbalanced diets; ⑤ Exercise regularly; ⑥ Control alcohol consumption and smoking; ⑦ Have regular blood lipid checks.