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.