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Metacarpophalangeal joint tendon xanthomas in a 45-year-old man with heterozygous familial hypercholesterolemia.

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Table 1. LDLc Target levels and levels Indicating Therapeutic Lifestyle Changes (TLC) and Drug Therapy

Risk Category

LDLc Target level,

mg/dL

LDLc level Indicating TLC,

mg/dL

LDLc level for Considering Drug Therapy,

mg/dL*

High risk:

CHD or CHD risk equivalent

(10-y risk >20%)

< 100

Optional goal < 70

>100

Moderately high risk:

More than 2 risk factors

(10-y risk 10-20%)

130

Optional goal < 100

>130

(100-129 may consider drug options)

Moderate risk:

More than 2 risk factors

(10-y risk 10%)

< 130

>130

>160

Lower risk:

0-1 risk factor

< 160

>160

>190

(160-189 LDL-lowering drug optional)

*The 2004 update recommended that when statin therapy is initiated in patients at high or moderately high risk, a dose and strength should be chosen that achieves at least a 30-40% LDLc reduction (see Table 3).

Table 2. Recommended Dietary Intake

Food Category	Typical US Diet	NCEP Diet	Diet for FH
Cholesterol, mg/d	500	< 200	100
Total fat, % energy (calories)	40	25-35	20
Saturated fat, % energy (calories)	14	< 7	< 6
Carbohydrate, % energy (calories)	45	50-60	65
Protein, % energy (calories)	Approximately 15	15	N/A

Table 3. Statin and Statin Combination Approved Doses, Expected LDLc Decrease, and Dose Required for 30-40% LDLc Reduction

Statin	FDA-Approved Dose	Expected LDLc Decrease	Dose Required for 30-40% LDLc Reduction
Atorvastatin	10-80 mg daily	35-60%	10 mg
Fluvastatin	20-40 mg at bedtime	20-30%	40 mg qd/bid
Fluvastatin	40 mg bid	35%	40 mg bid
Extended-release fluvastatin (Lescol XL)	80 mg at bedtime	35-38%	80 mg at bedtime
Lovastatin	20-80 mg at supper	25-48%	40 mg at dinner
Extended-release lovastatin (Altoprev)	20-60 mg at bedtime	25-45%	60 mg at bedtime
Pravastatin	40-80 mg at bedtime	30-40%	40 mg at bedtime
Rosuvastatin	10-40 mg daily	40-60%	5 mg daily
Simvastatin	20-80 mg daily at bedtime	35-50%	20 mg at bedtime
Simvastatin + ezetimibe (Vytorin)	10/20 mg 10/40 mg 10/80 mg at bedtime	50-60%	10/20 mg at bedtime

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Author

Mose July, MD, CCD Endocrinologist and Certified Clinical Densitometrist, Kymera Independent Physicians

Mose July, MD, CCD is a member of the following medical societies: American Association of Clinical Endocrinologists, Endocrine Society, International Society for Clinical Densitometry

Disclosure: Nothing to disclose.

Coauthor(s)

Omolola Bolaji Olajide, MD, FACE Associate Professor, Consultant, Department of Internal Medicine, Program Director, Fellowship Program, Section of Endocrinology, Joan C Edwards School of Medicine at Marshall University

Omolola Bolaji Olajide, MD, FACE is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, Endocrine Society, International Society for Clinical Densitometry

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Yoram Shenker, MD Chief of Endocrinology Section, Veterans Affairs Medical Center of Madison; Interim Chief, Associate Professor, Department of Internal Medicine, Section of Endocrinology, Diabetes and Metabolism, University of Wisconsin at Madison

Yoram Shenker, MD is a member of the following medical societies: American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

Romesh Khardori, MD, PhD, FACP (Retired) Professor, Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Additional Contributors

Gregory William Rutecki, MD Professor of Medicine, Fellow of The Center for Bioethics and Human Dignity, University of South Alabama College of Medicine

Gregory William Rutecki, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Nephrology, National Kidney Foundation, Society of General Internal Medicine

Disclosure: Nothing to disclose.

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