Red Flags
- LDL-C ≥190 mg/dL — likely familial hypercholesterolaemia; high-intensity statin and family cascade screening[1]
- Triglycerides ≥1000 mg/dL — risk of acute pancreatitis; urgent triglyceride-lowering therapy[1]
- Established ASCVD with LDL-C above goal on maximally tolerated statin — add ezetimibe; consider PCSK9 inhibitor[1]
- Lp(a) ≥50 mg/dL with personal or family history of premature ASCVD — independent risk enhancer[1]
First-line treatment
Interventions
- Lifestyle modification[1]Saturated fat restriction, increased fibre, ≥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-risk; 10–20 mg moderate-risk | — | First-line; LDL-C goal <70 mg/dL high-risk, <55 mg/dL very-high-risk ASCVD |
| Rosuvastatin[1] | HMG-CoA reductase inhibitor | 20–40 mg PO daily (high-intensity); 5–10 mg moderate | — | Alternative; preferred in renal impairment |
| Ezetimibe[1] | Cholesterol absorption inhibitor | 10 mg PO once daily | — | Add when statin alone insufficient; ~20% additional LDL-C reduction |
| Fenofibrate[1] | Fibrate | 145–160 mg PO once daily | — | For severe hypertriglyceridaemia (TG ≥500 mg/dL); avoid combining with statin if eGFR <60 |
Atorvastatin[1]
HMG-CoA reductase inhibitor (statin)
- Adult
- 40–80 mg PO once daily for high-risk; 10–20 mg moderate-risk
- Paediatric
- —
First-line; LDL-C goal <70 mg/dL high-risk, <55 mg/dL very-high-risk ASCVD
Rosuvastatin[1]
HMG-CoA reductase inhibitor
- Adult
- 20–40 mg PO daily (high-intensity); 5–10 mg moderate
- Paediatric
- —
Alternative; preferred in renal impairment
Ezetimibe[1]
Cholesterol absorption inhibitor
- Adult
- 10 mg PO once daily
- Paediatric
- —
Add when statin alone insufficient; ~20% additional LDL-C reduction
Fenofibrate[1]
Fibrate
- Adult
- 145–160 mg PO once daily
- Paediatric
- —
For severe hypertriglyceridaemia (TG ≥500 mg/dL); avoid combining with statin if eGFR <60
Safety-net
Referral criteria
- Triglycerides ≥1000 mg/dL with abdominal painEmergency department — risk of acute pancreatitis[1]
- Suspected familial hypercholesterolaemiaLipid clinic for genetic testing and family cascade screening[1]
- Established ASCVD not at LDL-C goal on maximally tolerated statin + ezetimibeCardiology / lipid clinic for PCSK9 inhibitor[1]
- Statin intolerance with multiple statinsLipid clinic for alternative agents (bempedoic acid, ezetimibe monotherapy, PCSK9 inhibitor)[1]
Clinical summary
ICMR-aligned management of dyslipidaemia for primary and secondary cardiovascular prevention with statin-first stepped therapy.