Dyslipidaemia management

Red Flags

LDL-C ≥190 mg/dL (≥4.9 mmol/L) — likely familial hypercholesterolaemia; high-intensity statin and family cascade screening^[1]
Triglycerides ≥1000 mg/dL (≥11.4 mmol/L) — risk of acute pancreatitis, urgent triglyceride-lowering therapy required^[1]
Acute coronary syndrome — initiate or intensify combination lipid-lowering therapy during the index hospitalisation per 2025 update^[1]
Lp(a) ≥125 nmol/L (≥50 mg/dL) — independent ASCVD risk enhancer; intensify lifestyle and lipid lowering and screen first-degree relatives^[1]

First-line treatment

Interventions

Lifestyle modification^[1]
Mediterranean-style diet, ≥150 min/week moderate aerobic activity, weight reduction if overweight, smoking cessation, alcohol moderation

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Atorvastatin^[1]	HMG-CoA reductase inhibitor (statin)	40–80 mg PO once daily for high or very-high CV risk; 10–20 mg for moderate risk	10 mg once daily for ages ≥10 with familial hypercholesterolaemia	LDL-C goal: <55 mg/dL (1.4 mmol/L) for very-high-risk ASCVD; <70 (1.8) for high-risk; <100 (2.6) for moderate; recurrent event within 2 years → goal <40 (1.0)
Rosuvastatin^[1]	HMG-CoA reductase inhibitor (statin)	20–40 mg PO once daily (high-intensity); 5–10 mg (moderate-intensity)	5 mg once daily for ages ≥10 with familial hypercholesterolaemia	Alternative to atorvastatin; preferred in renal impairment (no liver-mediated metabolism)
Ezetimibe^[1]	Cholesterol absorption inhibitor	10 mg PO once daily	10 mg once daily for ages ≥10	2025 update advocates EARLY combination therapy (statin + ezetimibe) rather than sequential up-titration; ~20% additional LDL-C reduction
Bempedoic acid^[1]	ATP-citrate lyase inhibitor	180 mg PO once daily	—	Statin-intolerant patients; 2025 update clarifies role; ~17% LDL-C reduction; CLEAR Outcomes trial showed CVD benefit
Evolocumab or alirocumab^[1]	PCSK9 monoclonal antibody	Evolocumab 140 mg SC every 2 weeks OR 420 mg SC monthly; alirocumab 75–150 mg SC every 2 weeks	—	For very-high-risk ASCVD or familial hypercholesterolaemia not at LDL-C goal on maximally tolerated statin + ezetimibe
Inclisiran^[1]	Small interfering RNA (siRNA) targeting PCSK9	284 mg SC at day 0, day 90, then every 6 months	—	Long-acting alternative to PCSK9 monoclonal antibodies; 50% LDL-C reduction with twice-yearly dosing

Atorvastatin^[1]

HMG-CoA reductase inhibitor (statin)

Adult: 40–80 mg PO once daily for high or very-high CV risk; 10–20 mg for moderate risk
Paediatric: 10 mg once daily for ages ≥10 with familial hypercholesterolaemia

LDL-C goal: <55 mg/dL (1.4 mmol/L) for very-high-risk ASCVD; <70 (1.8) for high-risk; <100 (2.6) for moderate; recurrent event within 2 years → goal <40 (1.0)

Rosuvastatin^[1]

HMG-CoA reductase inhibitor (statin)

Adult: 20–40 mg PO once daily (high-intensity); 5–10 mg (moderate-intensity)
Paediatric: 5 mg once daily for ages ≥10 with familial hypercholesterolaemia

Alternative to atorvastatin; preferred in renal impairment (no liver-mediated metabolism)

Ezetimibe^[1]

Cholesterol absorption inhibitor

Adult: 10 mg PO once daily
Paediatric: 10 mg once daily for ages ≥10

2025 update advocates EARLY combination therapy (statin + ezetimibe) rather than sequential up-titration; ~20% additional LDL-C reduction

Bempedoic acid^[1]

ATP-citrate lyase inhibitor

Adult: 180 mg PO once daily
Paediatric: —

Statin-intolerant patients; 2025 update clarifies role; ~17% LDL-C reduction; CLEAR Outcomes trial showed CVD benefit

Evolocumab or alirocumab^[1]

PCSK9 monoclonal antibody

Adult: Evolocumab 140 mg SC every 2 weeks OR 420 mg SC monthly; alirocumab 75–150 mg SC every 2 weeks
Paediatric: —

For very-high-risk ASCVD or familial hypercholesterolaemia not at LDL-C goal on maximally tolerated statin + ezetimibe

Inclisiran^[1]

Small interfering RNA (siRNA) targeting PCSK9

Adult: 284 mg SC at day 0, day 90, then every 6 months
Paediatric: —

Long-acting alternative to PCSK9 monoclonal antibodies; 50% LDL-C reduction with twice-yearly dosing

Safety-net

Statins are taken for life — stopping causes LDL-C and cardiovascular risk to climb back rapidly^[1]
Mild muscle aches are common and usually not serious; severe muscle pain, weakness, or dark urine — stop the statin and seek care^[1]
Routine LFT and CK monitoring not required unless symptoms develop — do not let lab fears delay therapy^[1]

Referral criteria

Triglycerides ≥1000 mg/dL with abdominal painEmergency department — risk of acute pancreatitis^[1]
Suspected familial hypercholesterolaemia (LDL-C ≥190, tendon xanthomas, premature CAD family history)Lipid clinic for genetic testing and family cascade screening^[1]
Established ASCVD not at LDL-C goal <55 mg/dL on maximally tolerated statin plus ezetimibeLipid clinic or cardiology for PCSK9 inhibitor or inclisiran^[1]
Lp(a) ≥125 nmol/L with personal or family history of premature ASCVDLipid clinic for risk-enhancer-aware management^[1]

Clinical summary

Risk-stratified management of dyslipidaemia for primary and secondary prevention, emphasising early combination therapy and Lp(a) screening.

References

1.2025 Focused Update of the 2019 ESC/EAS Guidelines for the management of dyslipidaemias (2025)