What is the recommended treatment for an 88-year-old patient with elevated Low-Density Lipoprotein (LDL) and total cholesterol levels, currently on Atorvastatin (Atay) 10 mg once daily, who has an allergy to statins, specifically HMG-CoA reductase inhibitors?

From the Guidelines

For an 88-year-old patient with statin allergies, LDL of 106 mg/dL, and total cholesterol of 159 mg/dL, I recommend discontinuing the Atorvastatin 10 mg and initiating ezetimibe 10 mg once daily as an alternative lipid-lowering therapy. Ezetimibe works differently from statins by inhibiting intestinal cholesterol absorption rather than blocking cholesterol synthesis in the liver, making it suitable for patients with statin intolerance 1. According to the 2022 ACC expert consensus decision pathway, ezetimibe is a recommended nonstatin agent for managing LDL-related ASCVD risk, with a mean percentage reduction in LDL-C of 18% as monotherapy and 25% in combination with statin therapy 1.

Key Considerations

• The patient's advanced age of 88 should be taken into account when considering the benefit-risk ratio of aggressive lipid lowering, and treatment goals should be individualized 1.
• Other options to consider include bile acid sequestrants such as cholestyramine or colesevelam, or PCSK9 inhibitors like evolocumab or alirocumab for more aggressive LDL reduction if needed 1.
• Lifestyle modifications including a heart-healthy diet low in saturated fats, regular physical activity as tolerated, and smoking cessation (if applicable) should be emphasized alongside medication therapy.
• Regular monitoring of lipid levels every 3-6 months after therapy change is recommended to assess response to the new treatment.

Ezetimibe Therapy

• The recommended dose of ezetimibe is 10 mg orally daily, with or without food, and it can be taken either 2 hours before or 4 hours after bile acid sequestrants (BAS) if used in combination 1.
• Contraindications to ezetimibe include a history of hypersensitivity to the medication, and warnings/precautions include not recommending its use in patients with moderate to severe hepatic impairment 1.
• Adverse effects of ezetimibe include upper respiratory tract infection, diarrhea, arthralgia, sinusitis, and pain in extremities, and it is generally well-tolerated with a generic version available 1.

From the FDA Drug Label

If myopathy is suspected, discontinue ezetimibe tablets and other concomitant medications, as appropriate When used in combination with a statin, fenofibrate, or other LDL-C lowering therapy, ezetimibe tablets is contraindicated in patients for whom a statin, fenofibrate, or other LDL-C lowering therapy are contraindicated.

The patient is allergic to statins and is currently taking Atay 10 mg once daily, which is likely ezetimibe.

• The patient's current treatment with ezetimibe is not contraindicated due to the statin allergy, as ezetimibe can be used as monotherapy.
• However, if the patient's LDL level is not adequately controlled with ezetimibe alone, alternative treatments may be considered, such as colesevelam.
• Colesevelam may be an option for this patient, but it is essential to monitor for potential interactions with other medications and to take vitamins at least 4 hours prior to colesevelam 2.
• Given the patient's age and potential for drug interactions, a conservative approach would be to continue monitoring the patient's LDL levels and adjust the treatment plan as needed, rather than introducing new medications that may have adverse effects.
• It is crucial to weigh the benefits and risks of any treatment change, considering the patient's overall health and potential for adverse reactions 3.

From the Research

Treatment Recommendations for High Cholesterol

Given the patient's allergies to statins, alternative treatment options must be considered. The patient is currently taking Atay 10 mg once daily, but the medication is not specified. Assuming Atay is a statin, the patient's allergies would necessitate a change in medication.

Alternative Treatment Options

• Ezetimibe: a cholesterol absorption inhibitor that can be used to lower LDL levels 4, 5, 6
• Bile acid sequestrants: can be used individually or in combination with ezetimibe to lower LDL levels 4, 5, 6
• PCSK9 inhibitors: may be considered for patients with high cardiovascular risk 7, 5

Considerations for Older Adults

• The patient's age (88 years) and cholesterol levels (LDL 106, total cholesterol 159) should be taken into account when determining the best course of treatment 8
• Statins have been shown to have a protective effect in older adults, but the patient's allergies must be considered 8

Treatment Goals

• The goal of treatment should be to lower the patient's LDL levels and reduce their cardiovascular risk 4, 7, 5
• The patient's individual values, preferences, and associated conditions and comorbidities should be taken into account when selecting a treatment option 7