The Endocrine Society has published a new clinical practice guideline on the assessment and management of lipid disorders in patients with endocrine diseases, including diabetes mellitus. The guideline was published in a recent edition of the Journal of Clinical Endocrinology and Metabolism.
Summary of Recommendations
The Endocrine Society Writing Committee, consisting of 10 experts in the fields of lipid disorders and endocrinology, commissioned the Mayo Clinic Evidence-based Practice Center to conduct 2 systematic reviews. The first systematic review evaluated studies investigating the effect of therapy for overt and subclinical hypo- and hyperthyroidism on serum lipid levels. The second review was used to estimate the magnitude of change in lipid parameters caused by weight loss.
The article below provides a brief summary of the recommendations made by the Endocrine Society based on the findings from the systematic reviews.
Screening and Cardiovascular Disease (CVD) Risk Assessment
The Endocrine Society opened their guideline by recommending the use of a lipid panel to assess triglyceride levels and calculate low-density lipoprotein (LDL) cholesterol in adults with endocrine disorders. In addition to the lipid panel, the Writing Committee recommends a more thorough cardiovascular risk assessment in these patients. This assessment might include calculating the patient’s 10-year atherosclerotic CVD risk using the Pooled Cohort Equations or similar tools.
Hypertriglyceridemia and Pancreatitis Risk
The Endocrine Society recommends pharmacologic treatment, in addition to diet and exercise, to prevent triglyceride-induced pancreatitis in patients who have a fasting triglyceride level >50 mg/dL (5.6 mmol/L). The Committee suggests plasmapheresis could be helpful for patients who do not respond to conventional triglyceride-lowering options. The Endocrine Society recommends against routine insulin infusion in patients without diabetes who have triglyceride-induced pancreatitis.
In contrast, insulin therapy is recommended for patients with uncontrolled diabetes. The addition of eicosapentaenoic acid ethyl ester is recommended to reduce the risk of CVD in patients who are receiving statins and still have moderately elevated triglyceride levels (>150 mg/dL), but only for those patients with either atherosclerotic CVD or diabetes plus 2 additional risk factors.
Type 1 and 2 Diabetes
The Endocrine Society recommends statin therapy to reduce CVD risk in those with type 1 diabetes as well as those aged ≥40 years and/or with a diabetes disease duration of >20 years. Statin therapy should be considered for these patients if levels of LDL cholesterol reach >70 mg/dL (1.8 mmol/L).
Statin therapy plus lifestyle modification are both recommended for patients with type 2 diabetes and CVD risk factors. Patients with atherosclerotic CVD or those at high risk for atherosclerotic CVD should take high-intensity statins. The guideline recommends an LDL cholesterol goal of <55 mg/dL (1.4 mmol/L) for patients with established CVD or multiple risk factors.
Obesity is a primary driver of metabolic syndrome. To determine CVD risk in patients who are obese, this clinical practice guideline recommends assessment of metabolic syndrome components, as well as measurement of body fat distribution in patients who are obese to determine CVD risk.
Diagnosis of metabolic syndrome, according to the guideline, includes the patient fulfilling 3 of the following criteria: elevated triglycerides ≥150 mg/dL (1.7 mmol/L); reduced high-density lipoprotein cholesterol <50 mg/dL (1.3 mmol/L) in women and <40 mg/dL (1.0 mmol/L) in men; systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥85 mm Hg; waist circumference of ≥40 inches in men and ≥35 inches in women; hyperglycemia.
The guideline recommends malabsorptive bariatric surgery procedures over restrictive procedures for decreasing LDL cholesterol levels in patients with obesity. Both types of procedures, however, are effective for reducing triglycerides. Clinicians are recommended to reassess the patient’s lipid profile from 1 to 3 months after bariatric surgery to monitor progress.
The Endocrine Society notes that hypothyroidism can cause increases in levels of cholesterol and triglycerides. As such, the guideline recommends ruling out hypothyroidism as the cause of hyperlipidemia in patients with elevated lipids, particularly before initiating treatment with lipid-lowering medications. Clinicians should reevaluate the patient’s lipid panel after the patient become euthyroid, the guideline adds. According to the Writing Committee, LDL cholesterol changes have been previously observed within 3 months after the patient becomes euthyroid.
Polycystic Ovary Syndrome (PCOS)
Since the presence of PCOS is associated with CVD risk factors, the Endocrine Society recommends obtaining a fasting screening lipid panel at time of diagnosis to evaluate CVD risk. The most common lipid abnormality in PCOS is hypertriglyceridemia. Lipid screening should be conducted before and during hormonal therapy, the guideline adds. Also, the guideline recommends against the use of lipid-lowering treatments for managing infertility or hyperandrogenism in women with PCOS.
The use of hormone therapy in women who have experienced menopause is also associated with increased CVD risk. In the Endocrine Society guideline, statin therapy is recommended for postmenopausal women who are taking hormone therapy and also have other CVD risk factors.
Newman CB, Blaha MJ, Boord JB, et al. Lipid management in patients with endocrine disorders: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2020;105(12):dgaa674. doi:10.1210/clinem/dgaa674