COLLABORATIVE

The primary treatment is dietary management, weight reduction, increased physical activity, and the restriction of saturated animal fat and cholesterol intake. Adding polyunsaturated vegetable oils to the diet helps reduce LDL-C concentration. Secondary treatment is aimed at reducing or eliminating aggravating factors, such as alcoholism, diabetes mellitus, or hypothyroidism. To reduce risk factors that contribute to atherosclerosis, the regimen includes treating hypertension, implementing an exercise program, controlling blood sugar, and stopping tobacco use. For type V hyperlipoproteinemia, female patients are taken off oral contraceptives. Medications may also be prescribed to lower the plasma concentration of lipoproteins, either by decreasing their production or by increasing their removal from plasma.

Target levels for lipoprotein are shown in Table 4.

Target Levels for Lipoprotein

LEVEL OF RISK	DEFINITION	TARGET LIPOPROTEIN LEVEL RISK
Low risk	All must be present: Nonsmoker; total cholesterol < 200 mg/dL, HDL-C > 40 mg/dL; systolic blood pressure (BP) < 120, diastolic BP < 80; no evidence of diabetes; not overweight; no family history of premature vascular disease	LDL-C should be lowered to < 160 mg/dL
Moderate risk	Does not fit in low-risk or high-risk categories	LDL-C should be lowered to < 130 mg/dL; consideration to lower LDL-C to < 100 mg/dL
High risk	Any of the following present: Known coronary artery disease or other vascular disease; type 2 diabetes; over age 65 with multiple (more than one) risk factors	LDL-C should be lowered to < 100 mg/dL; consideration to lowering LDL-C to < 70 mg/dL

In rare instances, for patients who cannot tolerate medication therapy, surgical creation of an ileal bypass may be necessary to accelerate the loss of bile acids in the stool and lower plasma cholesterol levels. For children with severe disease, surgery to create a portacaval shunt may be performed as a last resort to decrease plasma cholesterol levels. Plasma exchanges may also be used to reduce cholesterol levels.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Drugs that lower LDL-C	Varies with drug	Statins such as lovastatin, pravastatin, simvastatin, fluvastatin, and atorvastatin are the first line of therapy; bile acid sequestrant resins (cholestyramine, colestipol); nicotinic acid (niacin); 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors; estrogen in postmenopausal women	Lower the plasma concentration of lipoproteins either by decreasing their production or by increasing their removal from plasma
Drugs that increase HDL-C	Varies with drug	Nicotinic acid (niacin), estrogen in postmenopausal women	Lower the plasma concentration of lipoproteins either by decreasing their production or by increasing their removal from plasma

INDEPENDENT

Teach the patient about ways to manage diet to control the disorder. Urge the patient to adhere to a 1,000- to 1,500-calorie per day diet and avoid excess sugar intake. Explain the components of the lipid profile and their ramifications and discuss various means of lowering VLDL and LDL levels and increasing HDL levels. Several dietary additions are thought to reduce LDL cholesterol, such as 1.5 cups of oatmeal with fiber-containing fruit (soluble fiber reduces LDL), 1.5 ounces of nuts (walnuts, almonds, peanuts, pecans), olive oil, and fatty fish containing omega-3 fatty acids such as mackerel, lake trout, herring, sardines, albacore tuna, and salmon.

Explain the prescribed medication regimen, and provide verbal and written information to the patient or significant others. Refer to effective programs or support groups for controlling cigarette and alcohol use. Teach alternative methods of contraception to the female patient who can no longer use oral contraceptives.

A patient faces significant health threats unless he or she makes permanent lifestyle changes. Encourage him or her to verbalize fears, such as those concerning CAD. Offer support and provide clear explanations for the patient's questions about the lifestyle changes and consequences.