ABC | Volume 113, Nº4, October 2019

Updated Updated Cardiovascular Prevention Guideline of the Brazilian Society Of Cardiology – 2019 Arq Bras Cardiol. 2019; 113(4):787-891 Table 2.6 – Indications for the association of other lipid-lowering drugs (non-statins) Recommendation Recommendation grade Level of evidence Reference Ezetimibe When the statin treatment in the maximum tolerated dose does not reach the LDL-c target in very high-risk patients I B 7 When the statin treatment in the maximum tolerated dose does not reach the LDL-c target in patients in primary prevention IIb C 7 Alone or in combination with statins represents a therapeutic option for patients who do not tolerate the recommended doses of statins IIa C 7 Can be used in case of fatty liver disease IIb C 7 Resins Adding cholestyramine to the statin treatment can be recommended when the LDL-c target is not reached despite the use of potent statins in effective doses IIa C 7 PCSK9 Inhibitors Indicated for patients at high CV risk, on optimized statin treatment at the highest tolerated dose, associated or not with Ezetimibe, and who have not reached the recommended LDL-c or non-HDL-c targets* IIa A 7 CV: cardiovascular; HDL-c: high-density lipoprotein cholesterol; LDL-c: low-density lipoprotein cholesterol. In very high-risk patients and some high-risk situations, when the individuals already take statin at the highest tolerated dose and Ezetimibe, the addition of a PCSK9 inhibitor is reasonable, despite the lack of an established long-term safety (> 3 years) for this drug and its low cost-effectiveness according to current data. 20 Adapted from the Updated Brazilian Guideline for Dyslipidemia and Atherosclerosis Prevention. 7 Table 2.7 – Indication of medicines for the treatment of hypertriglyceridemia Recommendation Recommendation grade Level of evidence Reference Fibrates TG levels above 500 mg/dL I A 32,33 Mixed dyslipidemia with a prevalence of hypertriglyceridemia IIa B 32,33 In patients with diabetes, TG > 200 mg/dL, and HDL-c < 35 mg/dL, the combination of fenofibrate and statin might be considered when changing the lifestyle have failed IIa B 32,33 Nicotinic acid (niacin) There is no evidence that the drug benefits patients with controlled LDL-c III A 32,33 Exceptionally, it can be administered to patients with isolated low HDL-c and as an alternative to fibrates and statins, or in combination with these drugs in patients with hypercholesterolemia, hypertriglyceridemia, or resistant mixed dyslipidemia IIa A 32,33 Omega-3 fatty acids Patients with severe hypertriglyceridemia who did not reach the desired levels with the treatment can take high doses (4 to 10 g/day) of omega-3 fatty acids in combination with other lipid-lowering drugs I A 32,33 Supplementation with an E-EPA (ethyl eicosapentaenoic acid) formulation (4 g/day) can be recommended for high-risk patients with elevated TG levels using statins, as it seems to reduce the risk for ischemic events, including CV death* I B 32,33 CV: cardiovascular; EPA: eicosapentaenoic acid; HDL-c: high-density lipoprotein cholesterol; LDL-c: low-density lipoprotein cholesterol; TG: triglycerides. * This formulation is not commercially available in our country. Adapted from I Brazilian Guidelines on Fat Consumption and Cardiovascular Health. 32 associated with it, such as low HDL-c, 22-24 small and dense LDL particles, 25,26 insulin resistance, 27,28 and increased blood coagulability and hyperviscosity, 29-31 predispose the individual to atherosclerosis. According to Table 2.7, drug treatment for hypertriglyceridemia should be considered after the exclusion of secondary causes for the increase in TG – diabetes, renal failure, excessive alcohol intake, and use of certain medicines – and adjustments for behavioral measures. Table 2.8 presents the recommended doses of fibrates available in our country and their effects on lipid profile 803