Identification and Treatment of Patients with Homozygous Familial Hypercholesterolaemia: Information and Recommendations from a Middle East Advisory Panel

Abstract

We present clinical practice guidelines for the diagnosis and treatment of homozygous familial hypercholesterolaemia (HoFH) in the Middle East region. While guidelines are broadly applicable in Europe, in the Middle East we experience a range of confounding factors that complicate disease management to a point whereby the European guidance cannot be applied without significant modification. Specifically, for disease prevalence, the Middle East region has an established epidemic of diabetes and metabolic syndrome that can complicate treatment and mask a clinical diagnosis of HoFH. We have also a high incidence of consanguineous marriages, which increase the risk of transmission of recessive and homozygous genetic disorders. This risk is further augmented in autosomal dominant disorders such as familial hypercholesterolaemia (FH), in which a range of defective genes can be transmitted, all of which contribute to the phenotypic expression of the disease. In terms of treatment, we do not have access to lipoprotein apheresis on the same scale as in Europe, and there remains a significant reliance on statins, ezetimibe and the older plasma exchange methods. Additionally, we do not have widespread access to anti-apolipoprotein B therapies and microsomal transfer protein inhibitors. In order to adapt existing global guidance documents on HoFH to the Middle East region, we convened a panel of experts from Oman, Saudi Arabia, UAE, Iran and Bahrain to draft a regional guidance document for HoFH. We also included selected experts from outside the region. This panel statement will form the foundation of a detailed appraisal of the current FH management in the Middle Eastern population and thereby provide a suitable set of guidelines tailored for the region.

Fig. (1)

Low-density lipoprotein cholesterol (LDL-C) ranges in patients with familial hypercholesterolaemia (FH). Reproduced from 
Cuchel et al. Eur Heart J 2014; 35: 2146-57 [8], under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/).

Fig. (2)

Tendon xanthomas characteristic of homozygous familial hypercholesterolaemia (HoFH). Cutaneous and tuberous xanthomas in homozygous familial hypercholesterolaemia. Original photographs by Prof. Eric Bruckert and Prof. Frederick Raal. Reproduced from 
Cuchel et al. Eur Heart J 2014; 35: 2146-57 [8], under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/).

Fig. (3)

Genetic diversity of homozygous familial hypercholesterolaemia (HoFH).

Fig. (4)

Algorithm for the treatment of homozygous familial hypercholesterolaemia (HoFH). Caption: PEX, plasma exchange; LA, 
lipoprotein apheresis; PCSK9, proprotein convertase subtilisin/kexin type 9; CETP, cholesteryl ester transfer protein. Adapted from Cuchel 
et al. Eur Heart J 2014; 35: 2146-57 [8], under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/). Mipomersen licensed in US from age 12 years.