
The Philippine Heart Association, the Philippine Lipid and Atherosclerosis Society, and the Philippine Society of Endocrinology, Diabetes, and Metabolism, collaborated to develop the 2015 Clinical Practice Guidelines for the Management of Dyslipidemia in the Philippines (2015 CPG). These guidelines are meant to update the 2005 Clinical Practice Guidelines on the Management of Dyslipidemia in the Philippines (2005 CPG) . A panel of experts in the fi elds of dyslipidemia, cardiology, endocrinology and epidemiology were assembled to comprise the technical research committee (TRC) tasked to review available clinical evidence on dyslipidemia management. The main objective for this document is to develop clinical guidelines in the management of Filipino patients who are diagnosed with elevated cholesterol. This may infl uence standards and national policies for optimal patient care and cardiovascular health.

The physician may employ the recommendations confi dently in caring for most patients; however, this CPG is meant to defi ne practices that meet the needs of patients in most circumstances. The ultimate decision must be made by the Filipino physician and patient together, and should not be a replacement for clinical judgment.
SCOPE OF THE GUIDELINES
The scope of this CPG includes current statistics on the prevalence of dyslipidemia in our setting, recommendations on screening and monitoring using lipid profi le determination, identifi cation of groups at risk for cardiovascular (CV) events which will be targeted for prevention and treatment, and recommendations for the treatment of dyslipidemia for the prevention of CV events and mortality in Filipinos.
METHODS
The TRC initially reviewed the recommendations in the 2005 CPG and proposed clinical questions to be answered by the 2015 CPG. In order to update the 2005 CPG, the current guideline generally used the same methods as the earlier document. The TRC specifi ed the population, intervention and outcomes for each clinical question, and defi ned the criteria for eligible studies.
Table 1. Clinical Questions

CLINICAL QUESTIONS
The TRC developed an initial set of questions based on their expertise and from the 2005 CPG. From the initial document, nine (9) clinical questions (CQs) were prioritized and were used to provide the guidelines for the 2015 CPG.
CLINICAL OUTCOMES
Various clinical outcomes were rated and ranked using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) categories of importance. The clinical outcomes were rated numerically on a 1-to-9 scale following the GRADE categories, where a score of 7-9 is critical; 4-6 important; and 1-3, of limited importance. According to GRADE, ranking outcomes by their relative importance can help to focus attention on those outcomes that are considered most important and help to resolve or clarify disagreements.
CLINICAL OUTCOMES
The TRC designated the following outcomes to be CRITICAL with a score of 9:
CLINICAL OUTCOMES
• Total mortality • Cardiovascular deaths; • Fatal and non-fatal myocardial infarction and • Stroke or cerebrovascular disease Cardiovascular events was ranked as CRITICAL with a Score of 7. Coronary revascularization was assigned to be an IMPORTANT outcome with a GRADE PRO Score of 6. Additional important outcomes were added when deemed necessary for the particular clinical scenario (e.g., angina in ACS).
Table 2. Criteria for recommendation
With regards to the recommendation on the use of lipid profi le determination, draft recommendations were formulated so as to facilitate the implementation of the therapeutic interventions (e.g., lifestyle modifi cation, statins, and nonstatins) recommended in these 2015 CPG.
CPG CQs and Recommendations
For the 2015 CPG, we have nine clinical questions but only six statements. There were issues on clinical questions on non-statin therapies (CQs 4,6 and 9) so no statements were made. The TRC and the voting panel decided to provide a section on the use of non-statin therapy despite the lack of clinical data.
CPG CQs and Recommendations
Clinical Question 1 CQ1. Among patients diagnosed to have dyslipidemia, regardless of their present morbid condition or risk profi le, should lifestyle modifi cation (i.e., smoking cessation, weight management, regular physical activity and adequate blood pressure monitoring and control) be advised to reduce overall CV risk?
CPG CQs and Recommendations
The importance of lifestyle modifications, such as proper diet and exercise, has been repeatedly emphasized and been given increasing attention because of their relation to cardiovascular disease. The TRC recommends that lifestyle modification be advised to patients diagnosed with dyslipidemia regardless of their risk profile. Specific recommendations for this clinical question are on diet, exercise and smoking. Recommendations on adequate blood pressure control and weight loss are already documented in the guidelines of the Philippine Society of Hypertension (PSH) and Philippine Association in the Study of Overweight and Obesity (PASOO), respectively.
Statement 1.1 Diet
For individuals at any level of cardiovascular risk, especially those with established atherosclerotic cardiovascular disease (ASCVD), a low-fat, low-cholesterol diet, rich in fruits and vegetables, is RECOMMENDED.
Simple Dietary Plan for Fat Modification
In 2014, the FNRI released a simpler version of the food pyramid, which they termed as "Pinggang Pinoy" or "Pinoy Plate". It used a sciencebased approach with the best scientific evidence and compliments and supplements the food pyramid of the FNRI. It serves as a reminder to Filipinos on how to fill up their plates properly. A nineinch plate is advised, and distributing foods proportionally among the food groups provides approximately 1,200 to 1,500 calories per day. It is advised that half of the plate is composed of green leafy vegetables and one serving of fruit per meal. For fruits, 4 to 6 servings are encouraged per day. This updated guideline recommends that high-intensity statin therapy be used in secondary prevention of patients diagnosed with ASCVD. It should be emphasized that the definition of statin treatment intensity (Table 3) rests on the degree of LDL-C reduction, and less on the drug dose used.
Table 3. Statin treatment intensity

Statin Treatment Goal
In general, the 2015 CPG recommends a 30% or greater reduction in LDL-C for appropriate treatment goal with statin therapy, as trials on moderate-vs high-intensity statin therapy have shown a dosedependent response in terms of benefi t in the reduction of adverse outcomes. However, for purposes in clinical practice, a treatment goal LDL-C level of < 70 mg/dL may be recommended, as adapted by some international guidelines.
Statin Treatment Goal
Clinical Question 6 CQ 6. Among patients with ASCVD, should fi brates be given as an alternative to statins?
Statement 6
See section on non-statin therapy.
Statement 6
Clinical Question 7 CQ7. Among patients with acute coronary syndrome (ACS), should statin therapy be given?
Statement 7
For individuals with acute coronary syndrome, early highintensity statin therapy is RECOMMENDED and should be continued when already on statin therapy.
Clinical Questions 8
CQ8. Among patients with established ASCVD or diabetes, should lipid profi le determination be done?
Clinical Questions 8
Among patients without ASCVD but with multiple risk factors, should lipid profi le determination be done?
Statements 8
For individuals with evidence of ACSVD or diabetes, the use of the lipid profi le is RECOMMENDED for monitoring of treatment response since ALL patients with ASCVD should be on lipid-lowering therapy.
Statements 8
For individuals without evidence of ASCVD but aged > 45 years AND with 2 or more risk factors*, the use of lipid profi le for screening is RECOMMENDED.
Statements 8
For individuals on lipid-lowering therapy, the use of lipid profi le for monitoring of treatment response is RECOMMENDED. Due to the high cardiovascular risk of these patients from prolonged exposure to elevated LDL-C levels very early on in life, the lipid profi le should be carried out initially as screening, even younger than age 45 years, in patients with high index of suspicion (patients with elevated LDL-C levels > 190 mg/dL, signifi cant personal or family history of premature cardiovascular disease) then subsequently for monitoring treatment response since ALL patients with FH should be on aggressive LDL-C lowering therapy.
*

Screening of Familial Hypercholesterolemia Patients who fulfi ll the criteria for the diagnosis of familial hypercholesterolemia (Table 4) should be initiated therapy for aggressive LDL-C lowering

Lipid determination in secondary prevention
Since treatment is recommended among patients with ASCVD with or without diabetes, regardless of lipid levels, lipid profi le determination is not necessary for screening but for monitoring therapeutic response since ALL patients should already be on treatment. The role of the lipid profi le lies in its ability to determine the percent reduction or the level of LDL achieved after six weeks of treatment to 3-6 months thereafter. The time to achieve target levels based on the trials ranged from 1 to 8 years.
Lipid monitoring in diabetics in primary prevention
If the repeat levels are still below the desired reductions or LDL-C level, intensifi cation of lifestyle modifi cation and pharmacologic therapy is warranted. Statins can then be increased to the maximal dose tolerated.
Lipid determination in primary prevention
For individuals without evidence of ASCVD who are ≥ 45 years old and with 2 or more risk factors, the use of lipid profi le for screening is recommended. Moreover, lipid profi le determination is also needed to monitor treatment response. In the trials on primary prevention, the average reduction of TC and LDL-C was 20% and 29% respectively with a minimum duration of 1 year (range: 1.9 to 5 years) for benefi t to be achieved. Lipid profi le determination was done after 3 months of treatment and yearly thereafter. Lastly, based on the trials, monitoring of lipid profi le after 3 months of treatment is also recommended to determine achievement of treatment goals.
Lipid determination in primary prevention
To guide clinicians, Figure 2 outlines a proposed algorithm for the screening and treatment of patients. 
Monitoring for adverse drug reactions
Long-term treatment of dyslipidemia may bring about concerns for adverse drug reactions such as myalgias, myopathies and elevations of liver function tests.
Monitoring for adverse drug reactions
Baseline measurement of hepatic transaminase levels (alanine and aspartate aminotransferase) should be performed before initiation of statin therapy in patients at risk for developing liver injury. Serial liver function test monitoring in asymptomatic individuals are not recommended. However, should testing reveal elevations in transaminase levels during the course of statin therapy, the recommended course of action is outlined in Figure 3 . 
Statin-induced Myopathy
Statin myopathies are classifi ed as either myalgias, myopathies, myositis, or rhabdomyolysis (Table 5) . In patients at risk for development of statin myopathies, baseline creatine phosphokinase and subsequent monitoring should only be performed when symptoms are present. The TRC recommends a localized management algorithm for statintreated patients with muscle symptoms (Figure 4 ). 
Clinical Question 9
Among patients with ASCVD, should omega-fatty acids be given as an alternative to statin treatment?
Statement 9
See Section on Non-statin therapy
Non-statin Therapy
For diabetic and non-diabetic individuals with or without evidence of ASCVD, the use of fi brates and poly-unsaturated fatty acids (PUFA) or omega 3 fatty acids are NOT RECOMMENDED as alternative to statins for the secondary prevention of cardiovascular events.
Non-statin Therapy
The use of fi brates may be considered among patients with a high baseline TG > 204 mg/dl and low HDL-C < 34 mg/dl once LDL-C has been reached on a maximally dosed statin.
Combination Therapy
The TRC and the voting panel are in agreement that combination therapy of a non-statin therapy (eg: omega 3 FA, ezetimibe, fi brates) and a statin allows for a greater degree of LDL-C reduction and results in achievement of goal attainment for primary and secondary prevention.
Combination Therapy
However, there are no clinical trials to date supporting the use of more ideal combination therapies. Recommendations regarding combination of fenofi brate/statin and ezetimibe/ statin may be recommended only in patients who may benefi t from the combination treatment.
CONCLUSION
Six clinical statements were made by the TRC and the recommendations revolve around the holistic management of dyslipidemia. Lifestyle modifi cation should be recommended to all patients regardless of their CVD risk. High intensity statins are recommended to lower LDL-C by > 30% or < 70 mg/dl in the primary and secondary prevention of ASCVD, both for diabetic and non-diabetic patients. The simplifi ed algorithm was provided to serve as a quick reference in the management of clinicians.
CONCLUSION
The updated 2015 CPG is designed to be a guide for clinicians in managing dyslipidemia for the Filipino patient. This, however, should not replace sound clinical judgment by doctors and the ultimate decision for treatment should involve both clinician and the patient.

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