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Table 9 Screening of metabolic complications and management of dyslipidemia (see Tables 5 and 6 for diabetes management)

From: Management of endocrino-metabolic dysfunctions after allogeneic hematopoietic stem cell transplantation

1. Pre, and 3, 6, 12 months post bone marrow transplantation then yearly

- Triglycerides (TG)

- Cholesterol: HDL/LDL

- Fasting blood glucose, HbA1c

2. Prior to treatment, rule out hypothyroidism, nephrotic syndrome and cholestasis, by checking

- TSH, free T4

- 24-hour proteinuria,

- bilirubin and alkaline phosphatases

3. Then treat according to the cardiovascular risk (factors listed in Table 9 ),

- If high cardiovascular risk, dyslipidaemia must be treated.

- If low cardiovascular risk, treat according to

- severity of dyslipidemia

- prognosis of the transplantation.

- liver enzyme profile.

4. Adjust treatment according to LDL cholesterol and triglycerides levels

- Dietary and lifestyle measures always advisable.

- Modify the dose of immunosuppressantif possible as the 1st step

- If LDL cholesterol high and triglycerides <2 g/L: statin at the lowest dose to limit toxicity. NB pravastatin and fluvastatin, metabolized through alternative pathways = best choice in patients requiring co-administration of cytochrome P3A4 inhibitors

5. If mixed hyperlipidaemia or resistance to statin, add

- ezetimibe to statins, rather than increase the statin dose.

- fibrates but increases the risk of muscle disorders

6. If isolated hypertriglyceridemia >8 g/L

- fibrates alone to limit the risk of acute pancreatitis.

7. Follow-up

- Liver biology after 15 days and monthly after.

- If transaminases levels is >5 N and/or muscular pain, treatment must be stopped and CPK evaluation is required.

- Inform the patient of potential side effects so that he/she can alert his/her primary care physician