Use of statins in the management of hypercholesterolemia

Use of statins in the management of hypercholesterolemia

Erin D. Michos, MD, MHS, FACC, FASPC: Wow, we have a lot of work to do. Patients are not on target and we are underusing combination therapy. Some of this may be due to perceived or actual statin intolerance. Fortunately, we have new agents for LDL [low-density lipoprotein] overcast. In our next segment, we will delve into this; Let’s talk about treatment options for hypercholesterolemia. But in this segment, Jorge, can we at least lay the groundwork for why in all the guidelines, statins are still first line and why we should try to prioritize statins when we can? What is the evidence briefly behind statins?

Dr. Jorge Plutzky: There is incredible foundational evidence that statins are effective in reducing cardiovascular events. We’ve seen that progress since early trials of people with established cardiovascular disease and LDLs that were elevated in the 190 mg/dL range. We then go from there to see that people with lower degrees of risk still benefit from statin therapy. In those randomized placebo-controlled trials, they were very well-tolerated agents. That provides this foundation between efficacy in reducing events and safety and tolerability, and they’ve become our first resort, and now they’re generic and readily available, and they should be used. One of the things that we see is that they are not used enough, in terms of titration to higher doses. This is often necessary because the greatest effect you get is with the first dose, and as the titration increases, you will have less of an LDL-lowering effect with each titration. I think most of us in preventive cardiology do that, we go to higher doses. That record of evidence is very strong that lowering LDL with a statin will have benefits. Of course, a lot of thought has been given to the other effects they can have, pleiotropic or otherwise. But we know they work and we know they are generally well tolerated. Therefore, it is important to use them, even if we are also thinking about how to move on to additional interventions.

Erin D. Michos, MD, MHS, FACC, FASPC: Pam, we all know that statins have this overwhelming evidence of benefit and are a foundational therapy. But we also hear that patients are not achieving LDL goals in real-world practice. What is your approach when you have a patient on a statin who doesn’t seem to be meeting LDL goals? What are you thinking? How do you approach this in your clinical practice?

Dr. Pam Taub, FACC, FASPC: You always want to increase your statin titration to achieve your LDL goal, but statin intolerance is real. Studies estimate that between 5% and 30% of people have partial or complete intolerance to statins. This concept of partial statin intolerance is new, but also very important. Some people can only tolerate a certain dose, and it simply cannot be increased further or adverse effects are induced. So we have to recognize that intolerance to statins exists. We can’t fire our patients when they tell us they have adverse effects with a statin. The first thing I do is determine if there are any underlying metabolic disorders that I can correct that will help the patient not be statin intolerant. Some simple things you can do are check your thyroid levels, watch your vitamin D levels, assess your alcohol intake, look for other medications that could increase your statin level. Those are some simple things. If you just look at that, there’s a significant number of patients who can tolerate a statin.

After doing that, if they still have side effects with the statin, you need to find out what the maximum tolerated dose is. For most people, you can get at least a low dose of a statin. There are some patients whose maximum tolerated dose of statins will be 0, and this is where we have a lot of non-statin options. But ideally, we want patients to be on statins. Then there are all these non-statin options that we’re going to talk about that we can add. Many of these non-statin options, including PCSK9 inhibitors and ezetimibe, have good cardiovascular outcome data.

Transcript edited for clarity.

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