Hypocholesterolemia

Presentation

Role in disease

With the increased use of medication to suppress cholesterol, some have expressed concern that lowering cholesterol levels excessively will itself cause disease.

Specific disease entities

Demographic studies suggest that cholesterol levels form a U-shape curve when plotted against mortality; this suggests that low cholesterol is associated with increased mortality, mainly due to depression, cancer, hemorrhagic stroke, aortic dissection and respiratory diseases. It is possible that whatever causes the low cholesterol level also causes mortality, and that the low cholesterol is simply a marker of poor health.

Links with depression have been supported by studies. In contrast, no evidence was found for a link with hemorrhagic stroke (although higher cholesterol levels conferred a relative protection), and neither did statin drugs worsen the risk.

The Heart Protection Study found no increase in either respiratory disease or neuropsychiatric illness in a large trial population taking a statin drug.

Elderly

In the elderly, low cholesterol may confer a health risk that may not be offset by the beneficial effects of cholesterol lowering. Similarly, for elderly patients admitted to hospital, low cholesterol may predict short-term mortality. The prevalence of hypocholesterolemia in the elderly ranges between 2% and 36%, depending on specific cutoff levels and age range investigated. Alerting physicians to hypocholesterolemia may benefit some of their patients who take cholesterol-lowering drugs and decrease the rate of their emergency room visits.

Critical illness

In the setting of critical illness, low cholesterol levels are predictive of clinical deterioration, and are correlated with altered cytokine levels.

Causes

Possible causes of low cholesterol are:

• statins
• hyperthyroidism, or an overactive thyroid gland
• adrenal insufficiency
• liver disease
• malabsorption (inadequate absorption of nutrients from the intestines), such as in celiac disease
• malnutrition
• abetalipoproteinemia - a rare genetic disease that causes cholesterol readings below 50 mg/dL. It is found mostly in Jewish populations.
• hypobetalipoproteinemia - a genetic disease that causes cholesterol readings below 50 mg/dL
• manganese deficiency
• Smith–Lemli–Opitz syndrome
• Marfan syndrome
• leukemias and other hematological diseases

Diagnosis

Classification

According to the American Heart Association in 1994, only total cholesterol levels below 160 mg/dL or 4.1 mmol/L are to be classified as "hypocholesterolemia". However, this is not agreed on universally and some put the level lower.

References

References

1. (1992). "Report of the Conference on Low Blood Cholesterol: Mortality Associations". Circulation.
2. Suarez EC. (1 May 1999). "Relations of trait depression and anxiety to low lipid and lipoprotein concentrations in healthy young adult women". Psychosom Med.
3. (2004). "Hypercholesterolemia, HMG-CoA reductase inhibitors, and risk of intracerebral hemorrhage: a case-control study". Stroke.
4. (2002). "MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial". Lancet.
5. (2001). "Cholesterol and all-cause mortality in elderly people from the Honolulu Heart Program: a cohort study". Lancet.
6. (2003). "Serum cholesterol levels and in-hospital mortality in the elderly". Am. J. Med..
7. (2018-01-05). "The low indexes of metabolism intervention trial (LIMIT): design and baseline data of a randomized controlled clinical trial to evaluate how alerting primary care teams to low metabolic values, could affect the health of patients aged 75 or older". BMC Health Services Research.
8. (2019-10-12). "A Randomized Trial of Alerting to Hypocholesterolemia Results of the Low Indexes of Metabolism Intervention Trial-C (LIMIT-C)". Journal of the American Medical Directors Association.
9. (2001). "Relationship of hypolipidemia to cytokine concentrations and outcomes in critically ill surgical patients". Crit. Care Med..
10. (2011). "Hypocholesterolemia". Current Vascular Pharmacology.
11. (1989). "Serum cholesterol and triglycerides in hematological malignancies". Acta Haematol..
12. Criqui MH. (1994). Very Low Cholesterol and Cholesterol Lowering. Leaflet 71-0059. American Heart Association.