Management of complex lipid disorders in a community lipid clinic setting

Background/Synopsis

The management of patients with complex lipid disorders, including genetic dyslipidemias and treatment intolerance and resistance commonly occurs largely within specialized clinics in academic medical centers. Many patients who could benefit from such specialized services are cared for in community settings within primary care practices, however.

Objective/Purpose

To report the experience of a specialized lipid clinic in a community setting, with a focus on treatment efficacy and the detection of genetic dyslipidemias in a challenging patient cohort.

Methods

Patients from a large, multispecialty practice were referred to our lipid clinic, identified based on factors including intolerance to lipid medical therapy, difficulty reaching lipid targets, and/or suspicion of genetic dyslipidemias. Management was provided by a multidisciplinary team including lipid specialist physicians, genetic counselors, and a nutritionist, with support from a pharmacy team. Outcomes included baseline and follow up lipid measurements and the results of lipid genetic testing.

Results

In the first year of our lipid clinic experience, 61 patients were seen (40 female [66%], mean age 62y). Comorbid conditions included ASCVD (23%), hypertension (40%) and diabetes (12%). Statin intolerance was deemed to be present in 53% of patients at presentation, and 40% of patients were on no lipid-lowering medication at their first visit. Total and LDL cholesterol were both significantly reduced at a mean follow up of 6 months (total - 237 to 190 mg/dL; LDL - 151 to 107 mg/dL; both p<0.001). Lipid genetic testing was performed in 37 (61%), with pathogenic FH genetic variants found in 10 (27% positive rate, LDLR 8, APOB 2, all heterozygous). Follow up genetic counseling was offered, with appropriate recommendations for cascade (family) lipid screening and genetic testing. LDL levels were effectively reduced even in patients with statin intolerance and/or on no lipid-lowering medication at baseline, and those with genetically-confirmed FH (Table). In-clinic lipid nutrition counseling was performed for 22 (36%) patients. The proportion of patients without any lipid-lowering therapy decreased from 41% to 16%. Pharmacy prior authorizations and/or appeals were required for 21 patients (34%), of which 20 were successful.

Conclusions

Effective lipid management can be achieved in a multidisciplinary community lipid clinic for patients with highly complex lipid conditions with high baseline rates of medical therapy intolerance and/or those with genetic dyslipidemias. In addition, our observations suggest the possibility that, despite very high baseline LDL levels, those with genetic confirmation of FH may derive particular benefit from such management, perhaps related to the availability of relevant genetic insights reinforcing compliance and informing intensive treatment regimens. Our clinic may serve as a model for the delivery of advanced lipid management in non-academic, community settings.