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Episode 70: 2025 Algorithm for Management of Adults with Dyslipidemia Update Overview
00:26:48
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- [00:00]
A
Foreign welcome to ACE Podcasts. Thanks for tuning in as we elevate clinical endocrinology by taking deep dives into trends and topics that can help us improve our patient care and global health. Find the latest episodes on aace.com podcasts and now let's meet the endocrine experts who will be talking with us today.
- [00:28]
B
Hello and welcome to our ACE podcast, focused on ACE guidance documents. I'm Dr. David Lieb, professor of Medicine in the Division of Endocrinology at Eastern Virginia Medical School at Old Dominion University in Norfolk, Virginia. I also serve as our Endocrinology Fellowship Program Director. This episode will feature the 2025 algorithm for the management of adults with dyslipidemia. Joining me today are Dr. Shailendra Patel, chair of the algorithm, Dr. Maria Bilal Kazar, vice chair, and Dr. Robert Hegeli, who was an author and representative from the Canadian Cardiovascular Society. Thank you all for joining me today. Dr. Patel, could you please introduce yourself and tell us about your area of expertise and your role on the guideline?
- [01:15]
C
Happy to, David. And it's great to do this podcast again. I think we did one together when the lipid guidelines for ACE came out earlier this year. I'm a professor of medicine and an endocrinologist at the University of Cincinnati and also staff attending at the Cincinnati va. Although I'm here primarily from my academic hat my area of expertise generally sort of, I take care of neuroendocrine tumors in my sort of clinical practice as well. And my claim to fame, I suppose, is that my lab was the one that put the rare disease of cytosterelaemia on the map and investigated the pathways for this and showed the mechanism of how some of these proteins work to allow xenosterols to stay out of our bodies. And of course, I'm interested in rare genetic disorders like Smith lemniopit syndrome and cerebral tendon xanthoma disease, which are lipid disorders. So. And then my role on this particular algorithm was to be the chair. And like any good chairs, what you do is you surround yourself with absolutely amazing people who are experts. And to that reason, I have to thank not only Rob, who is actually on this panel, and Maria, who are a part of this podcast, but the rest of the crew who are really, absolutely fabulous and made my life completely very, very easy. And I want to call a shout out to our colleagues from Venezuela, Dr. Ponti, who represented the Latin American Academy of Science Study for Lipids and Cardiometabolic Risk. Rob, obviously he represents the Canadian Cardiovascular Society. And Fred Carpi, who was part of the European association for the Study of Diabetes. And of course, Ramiro Balderas from Mexico and Aman Rajpal from California, and Samina Afrin, who are part of our panel as well. So my job was to just get out of the experts and let them do their job.
- [03:14]
B
I love how international this committee was that helped to put together this, this algorithm. And Dr. Bilal Kazar gave. Can you tell us a little bit about your background and your role on the guideline, the committee?
- [03:26]
D
Sure. Thank you, David. So I'm a tenured associate professor in the division of Endocrinology and Metabolism at the University of Texas Medical Branch in Galveston. I became interested in cardiovascular disease and atherosclerosis. Before residency, I spent a year isolating lipoprotein fractions to study lipid oxidation in the postprandial state with Rob Evans at University of Pittsburgh. I completed my fellowship at Baylor College of Medicine and trained there in clinical and research lipidology with Drs. Christy Valentine and Larry Chan. And then I moved to Galveston, where I am right now. I founded and co directed for 10 years our lipid and cardiovascular prevention clinic. Currently, I'd say my interest in lipids rests mostly on triglycerides. I just love triglycerides because of the complexity of triglyceride metabolism, how they're influenced by, you know, so many factors, and how lifestyle has such a big impact. And then as a clinician educator, I enjoy helping trainees and colleagues understand lipid metabolism and the rationales for dyslipidemia treatment. Now, in terms of my role as vice chair of the task force, I echo what Dr. Patel said. I think we had the privilege of working with a great group of colleagues with different backgrounds, different countries on this common goal, which was the creation of this practical tool on lipid management for clinicians.
- [05:12]
B
Excellent. Thank you. And Dr. Hegeli, can you introduce yourself and tell us about your area of expertise and your role on the guideline?
- [05:21]
A
Thanks, Dr. Lieb. It's really my honor to be here, to be, to be among you, to be asked to participate. So I'm Rob Hageli. I'm an endocrinologist in London, Canada. That's in the province of Ontario. I basically am a lipidologist, I have a lipid clinic and I also have a long standing interest in the genetics of lipid disorders. So I also have a research lab where we use next generation sequencing to look into the genomes of our patients with liquid disorders. And as mentioned, I was representing Canada I'm a member of the Canadian Cardiovascular Society and so I've over the years have been a author on the Canadian guidelines for lipids, for management of lipids in the adults. And I've also been invited to serve on European guidelines, European Atherosclerosis Society guidelines. So I've been actually have quite a long involvement in translation of knowledge and trying to, you know, implement clinical care. I've got anyway, and this group was really a fantastic group of people to work with and really was a pleasure and an honor to be involved.
- [06:39]
B
Thank you all. Today we're discussing the new ACE dyslipidemia algorithm. This is an update to the 2020 algorithm and was informed by the recent ACE clinical practice guideline for the pharmacologic management of adults with dyslipidemia. Dr. Patel, can you tell us why it was important to update the algorithm in addition to the guideline?
- [07:00]
C
Like everything in life, I think that these are documents that need updating. And so the need to update, I think, happens to be something that we have to do every time we have new science, new data and new ways of practicing. So this was high time. 2025 is a good time to update something that's at least five years old. Plus, we are now entering a different level of sophistication in clinical science. Right. So, you know, we initially had science that was just translated, but people interpreted it. We are now getting much more professional in saying, let's look at the evidence base and then we come out with guidelines that are just evidence based. And that evidence base has improved because our ability to do really high quality clinical science has really improved. Right. We don't have just little case reports or whatever. We have amazingly good studies. So that evolution has led us to this point. And I think that our update of the lipid guidelines in, in January, that was published January, February, was really based on the fact that we are now beginning to use new tools to evaluate the science base. And our updated guidelines did that. And of course, it's natural to say now that we've got this, we need to update what really matters to the practicing clinician, right? The practicing healthcare worker who's going to be dealing with this and say we can't give them a very stodgy set of digested evidence base, but something that comes down to give me a quick way of quickly understanding the base and understanding what the practical matters are. And so this, a logarithm set is really long time overdue. And the biggest thing when we were discussing this internally was these are things that are universal. And if they're universal, we need to be able to say around the world who can we get to participate so that we come up with something that's going to last a little longer and be more applicable so more people can use it. And we clearly reached out to our professional societies around the around. We ended up getting the Europeans and the Latin Americans to participate, which I think is just amazing. And that improves our ability to say that when we give this advice it applies to everyone and it will last a little longer. So that's the reason for doing the updates. And I think that the goal of this a logarithm is to provide someone a very quick way way of looking at a problem and saying how do I dissect it quickly but base it in science so that the advice that's given, simple as it is, is really supported by some very strong science behind the scenes.
- [09:53]
B
And that's a great lead in to my next question. Dr. Bilalcazar, can you tell us what's new or different in the 2025 algorithm compared to the 2020 algorithm?
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A
Sure.
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D
So when I reviewed the 2020 algorithm, I was struck by how well organized and easy to follow the content was. The key information needed to evaluate and treat lipid disorders could just be found by looking at the figures in the document. This was something we wanted to emulate in the 2025 version. And I think thanks to the excellent team of lipid experts, our ACE editor, our graphic designers, I believe we were quite successful. We have a series of easy to read, colorful, updated evidence based slides that summarize what you need to know about lipid management and a narrative that provides more details and a rationale were needed. Now, in terms of the content, I would say that both algorithms recommend a patient centered, risk based based approach, but the 2025 version places a greater emphasis on shared decision making, health equity, individualized care. And I think part of that is because we had the intention of reflecting the ACE grade dyslipidemia guidelines that we used as a framework. Now in terms of specific examples of things in the algorithm that are new, for one thing, I think we did a pretty good job expanding on the of hypertriglyceridemia. So this algorithm details dietary and pharmacological interventions that vary depending on the degree and the severity of the hypertriglyceridemia and the treatment goals. Use of fibrates is limited to certain patients with severe hypertriglyceridemia for prevention of pancreatitis and niacin is no longer recommended in this algorithm. But one of my favorite updates, I think, is that we are offering a primer on lipid management for special populations. We address the issue of hiv, of people with hiv, pregnant patients, survivors of childhood cancer, et cetera. And we have those slides that are easily accessible and the narrative that gives further details. And then finally, like Dr. Hegeli pointed out, we do have a detailed slide on genetic dyslipidemias. And they summarize the clinical assessment, provide information on the genes. And I think this is becoming more and more important as genetic testing is now more accessible than it was, you know, five years ago.
- [12:52]
B
Say, absolutely, thank you. And Dr. Hegeli, I was gonna ask more about the special populations. As Dr. Balakazar mentioned, the updated algorithm highlights a variety of special populations. Can you share some more insight into those groups and how best to care for them?
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A
So I think this is one of the many unique features of this, of this algorithm. So I think in general, like, the whole, the whole effort, the whole project is just like a quantum leap above, like, you know, what I'm aware of that's already out there in the literature. But specifically, Dr. Lieb, about your question on special populations. So in addition to what Dr. Balakazar mentioned, so there is also the older adult. This is a question I get all the time in CMEs, like, what do you do for older adults? And, you know, are there any special considerations different? And so that, that's, that's one of the special populations that's dealt with adults with autoimmune disorders. So there is a huge overlap from many mechanistic points of view between autoimmune disorders and actually medications and dyslipidemia. And then Dr. Balcazar mentioned adults who are childhood cancer survivors and then transplant, again, the same issue in terms of the primary coma, comorbidity of the condition that required transplantation, but then also, you know, medications that are being used in the transplant patient. And then really some very innovative that I really haven't seen anywhere else. But for example, adults receiving gender affirming care. And obviously that, you know, has, you know, major impact potentially on lipid metabolism. So these are just some of the, some of the examples of some really unique aspects of this particular document. The other thing is, you know, in the genetics, the way that the genetics, again, both Dr. Patel and Dr. Bilal Pizarro mentioned the genetic populations. And it's a rare, it's a rare subset. But then in terms of, you know, when we're in the lipid clinic, they end up being enriched. You know, there's an enrichment. And just the way we've set that algorithm up, rather than starting, say, with the gene or the diagnosis or these, like, Fredrickson types that, you know, everybody was sort of forced to memorize, you know, so we sort of have thrown that out, and we just sort of start, okay, what's the primary lipid disturbance? And then you just follow the algorithm down and, you know, is it primarily triglyceride or is it like a combined hyperlipidemia, or is it like an HDL problem? And then very logically, you know, the sort of the causal genes and then even going down into clinical features and within the treatment pathway. So I think in addition to just sort of focusing on these special populations, I think just the whole logic and the whole structure of this algorithm and these set of algorithms is. Is unique from. From what I've seen in the long term.
- [15:56]
B
I love how practical this is because, you know, this is definitely something that, you know, I know endocrine fellows often struggle, you know, right before they take the board, there's all these different, very specific genetic mutations and things to memorize. And I think you can get fixated on some of the minutiae when really you just. You've gotta see the patient in front of you with the very specific lipid abnormalities and then kind of start from there. So it's. It's incredibly straightforward, I think, in that way, for the practicing clinician, for the. For the people that, you know, that I see in clinic. So now I'm gonna ask all three of you a question. And the question is, what key points should clinicians keep in mind when applying the new dyslipidemia algorithm in everyday practice? And I'll start by asking Dr. Patel.
- [16:46]
C
What key points would a practicing clinician want to do? I mean, I think that from any disease, any. Any pathology that you are trying to tackle, I think it's what's important for the patient. What are the goals of that therapy, and then what you hope to present to them as therapeutic options. What's the science base behind it? I think that if you keep it simple and say what's important to the patient, that's very important. And I think that being more centric to that, and that means not only what the patient thinks, but what their background is, what their culture is, what their economic status is, that allows them to kind of figure out whether things that we recommend are also affordable. Right. Is important. And I think at the end of the day, for atherosclerosis and Lipids, let's admit it, our primary goal is nearly always going to be focused around the atherosclerotic disease pathway. Right? I mean, why would you treat lipids unless there was clearly some pathobiology? And the biggest pathobiology is atherosclerosis. And that means are we making sure that we're changing, bending the curve away from cardiovascular morbidity, mortality? So I think those are the important things and you want to be able to make sure that the patient is also able to understand. So the provider needs to be able to translate the explanation of lipids to the patient because if the patient doesn't get the buy in, it doesn't matter how smart you are, you're not going to be successful. And I think our a logarithm by actually focusing on the simplification means that if a clinician were able to share that with the patient, I would hope that the patient actually gets to understand aspects of it as well. So you don't need in depth training to be able to read something that's simple. We started this process and I hope that next time someone revives it, they can actually build on some of these concepts so that they can make it better too. That's my spin on it.
- [18:52]
B
Absolutely. And Dr. Balakazar, same question.
- [18:55]
D
So what I was thinking is what I would like for this algorithm to do in the clinic is to increase awareness that lipid management goes beyond statins and that there are many patients that we see routinely in clinic that we don't even think that they need to be put on a lipid medication. You have patients with Mastle D or patients with hiv, like we said, that really benefit. So I invite our colleagues to look at the algorithm, have it in the clinic and see how it can be applied. I also think it's important that we share it with our trainees. Like you mentioned, this is a great learning tool for students, for residents, for fellows, for sure.
- [19:50]
B
And Dr. Hegel.
- [19:52]
A
Yeah. So I just, just actually just to sort of expanding on what was previously said. So the thing that's really struck me with it, you know, with the figures, with the key figures is, is that it is, it is really amenable. Like I could see it being applied at the point of care. So. So in our clinic, for instance, you know, we have like, you know, the desktop computers and then the screen and then often, you know, we turn them around and then, you know, show the patient or like try to do teaching off those. But then all of these, these algorithms fit so nicely. It's Just, you know, essentially, you know, the PowerPoint landscape format onto the, onto the screen and very simple flow and logical and, you know, and, and so even just then to use it to remind yourself for the practitioner, you know, at the point of care. Okay, how do you, you know what. And you can. So I think it would be in real time, you know, almost iterative, you know, you're going and using it. So it is useful in that way. And then I think also, you know, depending on now, not for every patient, but depending on the patient, you know, it can also be used so certainly training for our trainees, but then even possibly, possibly for the patient, just as a, just as, you know, to show the principles, the logic, here's what you have. You know, it has a name and there's, you know, a lot of people have done some thinking behind it and so on. So I think it's a, I think it's a fantastic roadmap and I, I'm, you know, starting to use it in, in my clinic in that way, just as a, you know, from. As a point of care tool.
- [21:31]
B
I love that you're using it in your clinic. So if one of the experts who's writing this algorithm is using it in their clinic themselves when they're in clinical practice, I think that says it all. Dr. Bilalcazar, where are some of the areas where we need more research or more evidence?
- [21:47]
D
Yeah. So first of all, I think it's important that we remember that clinical outcome data is really needed and that we can't just go by surrogate data. And this is the case, for example, for inclisiran, one of the medications that we talk about in the algorithm. We have good safety data. We show that it significantly reduces LDL cholesterol, but we really don't have the cardiovascular outcome data yet. So there is a gap. Then, of course, we have major gaps involving patients who are usually excluded from clinical trials. So the patients with severe hypertriglyceridemia, they're out pregnant patients. So we devote quite a bit in our algorithm to that specific population. But we need more data. And then finally, I think there's a big gap in practice that needs to be resolved, and that's the lack of access to the new lipid medications, you know, that we face with many of our patients because they're so expensive.
- [22:56]
B
I'm so happy that you brought that up because I think that's an incredibly important barrier for a lot of the people that we take care of. So it's important that those things are all included. Dr. Hegeli, are there medications on the horizon that we need to be paying attention to as endocrinologists?
- [23:14]
A
Yeah, so yeah, absolutely. For sure, for sure. Dr. Lieb. So I think the main ones right now, very imminent. And so these are these biologics. So the RNA directed therapies against Apoc3. So these have names like olizarrosin which is in sense oligonucleotide, and then there's Fosacyra or Fosaceran which is a short interfering RNA. So the same principle is say in glycerin for LDL. But then clozacerin and olazarcin are targeting RNA that is involved in triglyceride, the A4C3 which is involved in triglyceride metabolism. Anyway, these drugs have been extremely promising in the early phase clinical trials. In fact, olazarcin is already available and it has a place for severe hypertriglyceridemia. So the patient with like familial chylomicronemia syndrome or even refractory. So some patients that may, may not be purely Mendelian genetic, but we all have them. The patient that you try everything, they do, the good faith effort and they're still running triglycerides over a thousand that they're at the risk of pancreatitis. And we didn't have up until now we have not really had great treatment options. So those are a couple of examples. The other thing is there are a lot of drugs now being tested against LP delay. We didn't really talk very much about lp, but this is something to keep an eye on. I think we need to see the outcome trials. I've always been a little bit circumspect about LP for my whole career. I think it's amazing, I think it's very interesting. But you know, show me the outcome trial. So we'll have to wait and see a lot of other very interesting sort of fringe therapies. I think those are the main ones. I think the really especially the high triglyceride drugs. I think those are ones that would be of interest particularly to endocrinologists.
- [25:18]
B
It's exciting. You know, I was working with the third year medical student today in clinic and we saw an individual with familial hypercholesterolemia and just talking about all of the new drugs that have come out in the last five to 10 years and all the new drugs that are on the way. Lipidology is really one of the most exciting areas I think within endocrinology and I love having something colorful, logical, straightforward to go through with learners. But also, like you mentioned, the patients. It makes it easier, I think, for people to understand and accept the therapies once they understand why they need them. Like Dr. Patel, like you mentioned. Well, thank you all for joining me today. This algorithm is a practical and valuable resource, very valu resource that will help clinicians care for patients with dyslipidemia. By distilling the latest research into clear visuals and actionable guidance, it supports better treatment decisions and ultimately improves the care that we provide. To read the full algorithm, visit pro.ace.com clinical guidance thank you.
- [26:31]
A
Thanks for listening to another great ACE podcast. Join us for another episode@aace.com podcasts and help us in our mission to elevate clinical endocrinology. Together we are ACE.