What are the most common errors in the treatment of dyslipidemia?
Ian Graham: The first one would be to make a management decision based on a single lipid estimation. Laboratory error is unusual but it still occurs. It is important to have several estimations before making management decisions.
The next thing which is not infrequent and perhaps should be stressed more clearly in the guidelines is to consider secondary hyperlipidemia. There is a variety of causes which are listed but the commonest catch is a middle-aged person, perhaps a middle-aged lady, with hypothyroidism. Of course, unless you replace the thyroid deficiency, the lipid levels will remain elevated. That is a fairly common catch. In anybody in whom lipid levels do not respond or anybody in whom there is a clinical suspicion of hypothyroidism, thyroid function should be checked. Many people would recommend checking thyroid function anyway, particularly in middle-aged people, before initiating treatment.
Another thing to consider is hypertriglyceridemia. There is a lot of individual variability and some people with hypertriglyceridemia are extremely sensitive—just a lifestyle advice and do not necessarily need drugs. There are some people who respond extremely well to alcohol restriction and overall calorie restriction. In some people, a minority of people, triglyceride levels may normalize completely.
It is increasingly important to engage with the person or the patient in making management decisions. Very often these are asymptomatic people who are at high risk. Why would they want to be turned into a patient? Why would they want to take a tablet? One really does need to discuss the rationale for this and the fact that in high-risk people statins, for example, unequivocally reduce mortality. In that regard, a problem with statins, particularly in people without symptoms, is that nearly half of people stop taking them within a year. It is particularly important when discussing with the person to explain that these drugs work by blocking the enzyme that increases cholesterol but it does not destroy it. They only work if you take them. In general, statins, like antihypertensive treatment, should be taken lifelong, and this needs to be stressed with the person. This is not a drug to take for a few weeks until the cholesterol drops. It will go back up if the drug is stopped.