A Broader View: Evaluating Lipids and Cardiovascular Risk

A first-of-its-kind Endocrine Society clinical practice guideline recommends lipid profiles and cardiovascular risk assessment for patients with endocrine disorders.

Pay more attention to lipids and cardiovascular risk when you are treating people with endocrine diseases. That is the plea from the new publication, “Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline.”

“Hormones modulate every pathway involved in lipid metabolism,” says Connie Newman, MD, of the New York University Grossman School of Medicine, New York, N.Y., who chaired the panel that created the guideline. “Therefore it is not surprising that some endocrine diseases are associated with an abnormal lipid profile and increased risk of atherosclerotic cardiovascular disease. We hope that the guideline will make a lipid panel a routine test in adults with endocrine diseases and cause a greater focus on assessment of the risk of heart disease and stroke.”

“This guideline is the first of its kind. We wanted to provide guidance on an area where there was a gap in guideline recommendations,” Newman tells Endocrine News. Although there are many guidelines related to cholesterol, this guideline is noteworthy for its specific focus on lipid management in endocrine diseases. “With the exception of type 2 diabetes, endocrine diseases are not discussed in detail in cholesterol management guidelines,” Newman says.

Seeing the Whole Disease

Newman says that many endocrinologists may be surprised at a key recommendation to consider the lipid levels and cardiovascular risk factors of patients with endocrine disorders such as thyroid disease, Cushing syndrome, or acromegaly because they are so focused on treating the primary disorder. The guideline writers hope that endocrinologists will remember to broaden their views of endocrine disorders to include all the potential ramifications.

Specifically, the guideline recommends that adults with endocrine disorders have a lipid panel to assess triglyceride levels and calculate low-density lipoprotein cholesterol, as well as an assessment of traditional cardiovascular risk factors—including calculation of 10-year atherosclerotic cardiovascular disease risk using a tool such as the Pooled Cohort Equations.

“Hormones modulate every pathway involved in lipid metabolism. Therefore, it is not surprising that some endocrine diseases are associated with an abnormal lipid profile and increased risk of atherosclerotic cardiovascular disease. We hope that the guideline will make a lipid panel a routine test in adults with endocrine diseases and cause a greater focus on assessment of the risk of heart disease and stroke.” – Connie Newman, MD, New York University Grossman School of Medicine, New York, N.Y.; chair, guideline writing committee

The guideline also describes the use of coronary artery calcium measurement to refine risk assessment when the decision about statin treatment is uncertain.

More Aggressive Treatment in Diabetes

Newman notes that one of the most important points of the guideline is to consider statin therapy at an earlier age in adults with type 1 diabetes who have obesity, vascular complications (such as retinopathy or kidney abnormalities as indicated by albumin in the urine), or a 20-year history of diabetes.

“We believe strongly that adults who have type 1 diabetes should receive statin therapy earlier than they usually do,” Newman says, although she emphasizes that this is not one-size-fits-all, but a hope that endocrinologists will give stronger consideration to the use of statins than has happened in the past.

The consideration for more aggressive treatment applies to type 2 diabetes as well. “In adults with type 2 diabetes and other cardiovascular risk factors, we recommend statin therapy in addition to lifestyle modification in order to reduce cardiovascular risk,” the guideline says. If statin therapy is not successful in meeting low-density lipoprotein and triglyceride goals in these patients, the guideline suggests adding eicosapentaenoic acid ethyl ester (or a fibrate if this is not available) to reduce cardiovascular risk.

Thyroid Disease and Cushing Syndrome

When a clinician encounters a patient with hyperlipidemia, the guideline recommends ruling out the possibility of hypothyroidism before prescribing a lipid-lowering medication.

“Thyroid hormone affects lipid pathways,” Newman notes, so a meta-analysis of the literature done as part of the guideline-writing process provided evidence to confirm that treating a patient’s hypothyroidism could improve lipid levels. Once a patient’s thyroid hormones are in the normal range, the guideline recommends re-evaluating the lipid profile. It recommends the same approach in patients with subclinical hypothyroidism who have hyperlipidemia, because thyroxine treatment could reduce low-density lipoprotein levels without the use of statins.

In adult patients with Cushing syndrome, the guideline recommends monitoring the lipid profile to identify cases of dyslipidemia. In adults with persistent endogenous Cushing syndrome, the guideline suggests statin therapy as an adjunct to lifestyle modification to reduce cardiovascular risk regardless of the patient’s cardiovascular risk score. In adults whose Cushing syndrome has been treated successfully, the guideline advises that the approach to cardiovascular risk assessment and treatment should be the same as in the general population.

Specifics on Other Endocrine Disorders

In adults receiving chronic glucocorticoid therapy above replacement levels, the guideline suggests assessment and treatment of lipids and other cardiovascular risk factors because of the increased risk of cardiovascular disease associated with the steroid therapy.

Specifics on other disorders include:

• Recommending that adults with growth hormone deficiency have a lipid profile done at diagnosis to assess for dyslipidemia;
• Suggesting that adults with acromegaly have lipid profiles done before and after treatment of growth hormone excess;
• Advising that patients with very low high-density lipoprotein levels be investigated for anabolic steroid abuse; and
• Recommending a fasting screening lipid panel at diagnosis in women with polycystic ovary syndrome to assess cardiovascular risk.

Menopausal Considerations

The guideline has some recommendations relating to post-menopausal patients as well. It recommends treating high cholesterol or triglycerides in post-menopausal women with statins rather than hormone therapy because hormone therapy is considered a risk factor for increased cardiovascular disease.

“The guideline evaluates the degree to which treatment of the endocrine disease improves dyslipidemia and makes recommendations about the use of lifestyle modification and medications to lower lipids and lipoproteins.” – Connie Newman, MD, New York University Grossman School of Medicine, New York, N.Y.; chair, guideline writing committee

Women who enter menopause early (before the age of 40 – 45 years) should have their cardiovascular risk factors and lipid levels assessed and be treated as needed, keeping in mind that early menopause raises cardiovascular disease risk. “You don’t always think about that when you see a patient who has what we used to call premature menopause,” Newman says.

Newman says that the guideline, which was cosponsored by the European Society of Endocrinology and published in the December print issue of The Journal of Clinical Endocrinology & Metabolism, contains a wealth of information that endocrinologists will find useful in treating a variety of disorders: “The guideline evaluates the degree to which treatment of the endocrine disease improves dyslipidemia and makes recommendations about the use of lifestyle modification and medications to lower lipids and lipoproteins.”

Seaborg is a freelance writer based in Charlottesville, Va. In the December issue, he wrote about the underlying threats of primary aldosteronism.

“Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline” is available online.