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Lifestyle Interventions must be made before giving treatment. If lifestyle interventions not working, resort to treatment guidelines

Lifestyle modifications must always be done during pharmacological treatment

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Based on MOH guidelines LDL cholesterol target levels,
Very High Risk: <2.1 mmol/L
High Risk: <2.6 mmol/L
Intermediate Risk: <3.4 mmol/L
Low Risk: <4.1 mmol/L

Risk can also be assessed by patient's age, BP, Lifestyle choices e.g. smoking, Race etc.

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Binds with bile acids to prevent reabsorption.  This promotes hepatic conversion of cholesterol into bile acids and hence increase LDL receptor activity of liver cells which increase clearance of LDL from the plasma.

Dose:
- Cholestyramine 4g (1 sachet) OD-BD
-  Maximum --> 24g (for hyperlipidaemia)

Side Effects:
- Constipation
- Diarrhoea
- Nausea
- Vomiting
- Flatulence

Contraindications:
- Complete biliary obstruction --> Not likely to be effective

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5 Main Pharmacological Classes of Drugs 

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5 Main Pharmacological Classes of Drugs 

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Non-pharmacological method to reduce the risk of CAD.

exercise more frequently such as 150-300 mins/ week of moderate intensity aerobic activity for about 5 to 7 days per week.
- it will help to decrease triglyceride and increase HDL. It will also increase the size of LDL to reduce the harmfulness

Stop smoking as cigarette smoking will damages the walls of blood vessels, making them likely to accumulate fatty acids which increase the risk of heart attack.
- stop smoking will increase the level of HDL and this will reduce the risk of CAD.

Have a healthy diet
consumption of trans fat, increase LDL and reduce HDL
- should have a balance meal of 50% whole grains, 25% fruits and vegetables and 25% protein to reduce the amount of cholesterol and triglyceride (due to over carbohydrate)

Have a maintain BMI range of 18-23 kg/m^2
If above BMI of 23kg/m^2, it means that the patient is obese. Obese plays an important role in atherosclerosis and CAD. It will put a high risk of cholesterol and affecting the structural and functional change of the heart.
- maintain a healthy BMI to reduce the risk of CAD by having healthy diet and exercise regularly.

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MOA: Inhibits intestinal absorption of cholesterol
- Add on drug with statin

Dose: 10mg OD
Side effects:  Fatigue, Diarrhoea, Myalgia, Arthralgia, Upper respiratory tract infection
Contraindication: Concomitant use with statin in patients with active hepatic disease or unexplained persistent elevations in serum transaminases, pregnancy and breastfeeding (with concomitant use with Statin)
Counselling points: may be taken with or without food

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Decreases serum TG (mainly) and increases HDL and LDL

Used in severe hypertriglyceridemia, where fibrates alone may not adequately lower TG levels

Side effect: Dyspepsia, nausea

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Activates of peroxisomes proliferator-activated receptor-α (PPAR- α) and lipoprotein lipase, which decreases VLDL levels

Side effects:
- Fenofibrates --> Abdominal distension, anorexia, diarrhoea, nausea
- Gemfibrozil --> Abdominal pain, constipation, diarrhoea, dyspepsia

Dose:
- Fenofibrates --> 200mg - 267mg, OD. When used with Statins, 200mg OD is the maximum dose.
- Gemfibrozil --> 600mg, BD

Remarks:
- Fenofibrates --> Preferred fibrate to be used with statins
- Gemfibrozil --> Should not be given together with statin.

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Competitively inhibits HMG-CoA reductase (enzyme involved in cholesterol synthesis in the liver)
Very effective in lowering LDL and TC

Side effects:
Altered liver function test

GI disturbances

Headache

Myalgia (Muscle pain)

Myopathy (Muscle weakness)

Rhabdomyolysis (Muscle breakdown) -->  Presents as unexplainable generalised muscle pain, stiffness or cramps, muscle weakness and dark urine.

Jaundice -->  Presents as yellowing of skin, yellowing of the whites of the eyes and dark urine.

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- Fibrates
- Omega 3 fatty acids are added as an adjunct

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Recommend Fibrates alone

-first line  drug to reduce risks of pancreatitis when Triglycerides is more than 4.5 mmol/L
If Fibrates does not help to reduce the triglyceride level and the Triglyceride level is still more than 4.5 mmol/L, optimized dose then add omega 3 fish oils or niacin to reduce the very high triglyceride level.

When there is still a very high range of LDL and very high TG( more than 4.5 mmol/L) after using fibrates, statin can be added with fibrates to help reduce the elevated LDL as it is the most effective in lowering the LDL levels.

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First-line drug: Statin
If condition not improved, add on Ezetimibe, followed by Fibrate/Niacin

Ezetimibe:
Cholesterol Absorption Inhibitor (inhibits absorption of cholesterol)
Used as an add on with statins
Dose: Ezetimibe 10mg added with statin
(this produce a further 18% lowering of LDL levels)
Similar effect to doubling the dose of statin 3 times

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First line drugs: Statins
If condition not improved, add ezetimibe