AACE Publishes Guideline on Drug Management of Dyslipidemia

A new dyslipidemia guideline from the American Association of Clinical Endocrinology (AACE) offers evidence-based recommendations for the use of newer drugs and focuses on outcomes that are important to patients.

The guideline applies to adults 18 years of age or older who have dyslipidemia or hypertriglyceridemia and who are receiving standard-of-care treatment, but also are not at goal and may consider additional medications. 

“Many of the recommendations are in line with other guidelines and current practice; however, clinicians may be surprised in the limited benefit of newer medications for several cardiovascular outcomes,” guideline authors Shailendra Patel, DPhil, and Kathleen Wyne, MD, PhD, told Medscape Medical News.

“Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework, the task force viewed the evidence for individual patient-important outcomes and found only small or no differences in cardiovascular events with the newer PCSK9 inhibitors,” they said.

“Additionally, limited evidence was available to support widespread use of nontraditional risk factors for atherosclerotic cardiovascular disease (ASCVD) risk assessment such as coronary artery calcium, lipoprotein(a), and apolipoprotein B,” they said. 

“In fact, addition of these tests provided only small increases in the ability to accurately assess risk,” they noted. However, these tests may still provide some utility for individuals who are at intermediate risk and would like additional information in deciding on treatment.”

The clinical practice guideline was published online on February 5 in Endocrine Practice.

Guided by GRADE

The “biggest change” from the AACE 2017 guideline was the use of the GRADE methodology and assessment of the certainty of evidence “at the outcome level instead of study level,” Patel and Wyne said. This change led to a different recommendation for cholesterol treatment goals.

“The previous guideline recommended lower low-density lipoprotein C (LDL-C) targets of 55 mg/dL or below, based on one large trial. With the availability of more trials assessing multiple agents, there was a small benefit in the risk of heart attacks and mortality with achieving an LDL-C goal of

Clinicians should use their judgment and shared decision-making when developing treatment plans that consider patient preferences/values, costs, acceptability, and equity, they added.

Key Highlights

The guideline was developed by a multidisciplinary task force of content experts and guideline methodologists, based on several literature searches for systematic reviews of randomized controlled trials or cohort studies from database inception through May 31, 2024. It includes 13 evidence-based recommendations for the pharmacologic management of adults with dyslipidemia, focused on patient-important outcomes of ASCVD risk reduction. Among the highlights:

• The task force suggested the use of alirocumab, evolocumab, or bempedoic acid in addition to standard care for adults who have ASCVD or who are at increased risk for ASCVD.
• The task force suggested against the use of those medications in adults without ASCVD.
• There was insufficient evidence to recommend for or against the addition of inclisiran.
• For adults with hypertriglyceridemia and ASCVD or at increased risk for ASCVD, the task force suggested the use of eicosapentaenoic acid, but not eicosapentaenoic acid plus docosahexaenoic acid. It strongly recommended against the use of niacin.
• There was insufficient evidence for recommendations regarding pharmacologic management in adults with severe hypertriglyceridemia (≥ 500 mg/dL).
• The task force suggested an LDL treatment goal of

In a related editorial, Ricardo Correa, MD, EdD, Cleveland Clinic, Ohio, commented that AACE’s adoption of the GRADE methodology “provides recommendations based on the best available evidence. [It] reflects the evolving understanding of ASCVD risk management and the need for ongoing research to establish optimal treatment targets and the need to guide shared decision making for diverse populations, ultimately supporting improved cardiovascular outcomes for a broad patient population.”

To facilitate implementation, the task force provided a flow diagram for the summary of recommendations, an overview of medication table, and key clinical considerations for each recommendation. A patient summary of the guideline is also available.

The clinical practice guideline for dyslipidemia pharmacotherapy was developed with financial support from AACE. AACE received no outside funding for the development of this guidance document. Task force member disclosures are available in Appendix A of the paper. Correa reported serving as immediate past chair of the AACE CPG Oversight Committee, member of the AACE Board of Directors, and in leadership positions at the American Medical Association, Western Endocrine Association, American Federation for Medical Research, American College of Physicians, and Endocrine Society. 

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.