Opening Remarks: Dyslipidemia in Women

I feel honored to contribute to this special issue on lipid disorders in women in the form of a preface to IJCDW.

There indeed is a great need to research the available data from various sources and come out with guidelines to be followed for the benefit of Indian women with dyslipidemia. The format is well laid out, and all the contributing authors have done a great job.

Hemanth Satpathy has given a panoramic view of dyslipidemia in pregnancy and how to rectify it.^[1]

Dayasagar Rao et al.^[2] have well discussed the need to have targeted guidelines for Indian women.

Satyanarayanan et al.^[3] have given a nice contribution to understanding the genetic and ethnic determination of dyslipidemia in women and also discussed the paucity of data pertaining to women in various clinical trials.

Oruganti Harish et al.^[4] have discussed the implications of LP(a), remnant cholesterol, and non-high-density lipoproteins (HDL) cholesterol in women. This is a lesser-known domain in lipid understanding in all and specifically in women.

Palimkar et al.^[5] have gone into the futuristic novel agents and their safety, efficacy aspects. This will add to our current pharmacotherapeutic strategies.

Mohan et al.^[6] have elucidated on statin therapy in Indian women with dyslipidemia and the role of nonpharmacological strategies.

Pechetty et al.^[7] have discussed the role of inclisiran and Small interfering - Ribonucleic acid (siRNA)-based lipid-lowering agents. This new frontier will be a very exciting prospect in the near future.

Ritu Bhatia^[8] has delved into new HDL-targeted therapies. As we know, we have very few current options to deal with HDL.

Takahashi Saeko et al.^[9] have given us gender-specific guidelines insight for our clinical practice.

Darimireddi Anuradha et al.^[10] have us peep into the diagnosis of subclinical atherosclerosis in women which is of great significance in the prevention of atherosclerotic cardiovascular disease in women.

Mahilmaran A et al.^[11] have discussed dyslipidemia across the biological and physiological life span of women and gender differences along with hormonal impact.

An important chapter includes very compehrensive consensus statement which summarized all current knowledge, information, and guidelines, specifically with Indian women in focus.

I am indeed very impressed with the effect of producing and compiling various aspects of dyslipidemia in Indian women and the accompanying guidelines.

Dyslipidemia in women is grossly under recognized due to markedly under testing and the age-old belief that heart attacks are not a major problem in women. But it is important to recognize that cardiovascular disease is the no 1 cause of death in women, particularly after 40 years of age.

This misconception has led to under investigation, under diagnosis, therapeutic inertia with disastrous consequences. This bias has to be set in the right perspective and we need to sensitize the public, doctors particularly family physicians and medical students.

As has been highlighted in the concensus statement it has to be taught in schools and medical schools the importance of early and repeated lipid testing at all stages of harmonic life of women. Emphasis needs to be given to serum triglycerides, LP(a), lipoprotein -B, Non HDL chol and small low-density lipoprotein (LDL) as well as total LDL.

It is painful to note that they are brushed off as being inconsequential, Recognising dyslipidemia and dealing with them is life insurance for the future. The current therapeutic inertia and therapeutic nihilism should be blown away from the minds of the medical fraternity.

The importance of diet discipline and physical activity cannot be over emphasized. I hope that the cost of testing, ease of testing and cost of medicines also need to be built into the perspective.

Artificial intelligence incorporated into medical records can act as a black box gateway to remind physicians to think about and act on lipids pathology. Lipidology has emerged as a sub-subspeciality in some countries like the USA and is a welcome development. But we notice that very discouragingly lipidology is hardly ever taught or emphasized in under graduate (or) post graduate medical curriculum.

Unlike the past, now we are in a therapeutic happy position with a wide band of molecules for most patients of various sub groups, though they continue to be expensive from the patient perspective. Fortunately, most of them come with no life endangering complications. We also have the good option of twice or once monthly injectables subcutaneously which make the compliance much better but for the financial burden of cost as of now.

Hopefully once they are off patent and generics are available or when bioequivalents with similar pharmacological benefits are researched in India, this may not be a big problem. From the technological future perspective genetic engineering involving gene replacement, gene silencing and gene balancing are as and when available, we may find a permanent cure solution.

Plasmapheresis and liver transplant are other possibilities particularly in homozygous hypercholesterolemia.

Organization of lipid clinics, lipid labs and lipid specialists can give a big opening to optimal detection and management of lipid pathologies. lipidspecialists nutritionists, lifestyle specialists also need to be made part of these clinics

Home monitoring can be organized with the help of home healthcare workers. The most difficult strategy among all of these is inculcating diet discipline and physical activity. Schools and teachers can play a big influential role.

Primary health care centers and even government hospitals including medical education centers do not have adequate lipid testing facilities leave alone total profile testing

Strategies suggested are:

• Identify high risk/intermediate Risk population.

• Polypill strategy

• School strategy

• Home testing

• Home monitoring

• Testing in primary health care centers

• Package for risk factor testing

• CME - Family physicians, Nurse practitioners

• Mass scale diet strategies.

• Family/parental education

• Govt policies

• Cost of testing – Govt labs can play a big role

• Point of care testing

• Reduce cost of drugs

• Role of Jana Aushadhi pharmacy and govt hospital dispensaries.

The Consensus statement has well pointed out the exclusivity of Indian patients and with women in focus. The recommendations have taken into consideration the needs of the Indian women and the treatment needs. The pointed focus on changes with menopause, pregnancy and location, with the specific needs have been well highlighted. Crystal balling into future needs and the growth of future of Lipidology therapeutics is brought out in a concise form. This is very pertinent in view of changing scenarios in the need, availability of medicines and the new future explosion of multiple options in our therapeutics armamentarium. Diffusion of this knowledge is very important. It should percolate to the basal level where medical service providers are responsible for medical care in almost 70% of medical contacts between public and hospitals.

It is also the responsibility of the government to see that the needed lab facilities and medicines are available at affordable prices. All along we were in disadvantage due to paucity of access to lab facilities and even more importantly lack of knowledge in the medical service providers. And we hardly had any Indian data sets to work on and make confident and reliable recommendations to our Indian women patients and general population. Atleast now we have our own research scientific data to fall back on and advise sensibly and with authority backed by the data. Cardiovascular atherosclerotic disease and lipidology in women are very unique and distinct entities requiring focus.

Still there are important barriers to apply and translate into action for the benefit of women which includes a lack of awareness, lack of access, expensive lab facilities, costly new medications, therapeutic inertia and physician apathy to try to reach therapeutic and clinical targets after initiation of treatment. There is also lack of follow up and encouraging non pharmacological strategy along with medical therapeutics. It is important to discuss with the patients and family at the first contact itself and continue to monitor and encourage the patients to follow up the strategies as preventive measures cannot show immediate dramatic results.

The methodology adopted and the framing of 20 key questions is very accurate and obviously lot of effort has gone into structuring this very needed and useful consensus document. Congratulations to the team involved in this elaborate exercise.