From the Guidelines
For an 88-year-old patient with an LDL level of 106 and a total cholesterol of 159 who is on ezetimibe 10 mg once daily and has allergies to statins, the recommendation is to continue ezetimibe and consider adding a PCSK9 inhibitor such as evolocumab (Repatha) 140 mg subcutaneously every 2 weeks or alirocumab (Praluent) 75-150 mg subcutaneously every 2 weeks, as these agents have been shown to provide significant LDL reduction and cardiovascular benefit in patients with atherosclerotic cardiovascular disease (1).
When considering additional therapy in this elderly patient, it's essential to weigh the potential cardiovascular benefits against the burden of additional medications, cost considerations, and the patient's overall life expectancy and goals of care. The patient's current lipid profile is relatively reasonable for their advanced age, but if additional LDL reduction is needed, a PCSK9 inhibitor can provide complementary lipid-lowering effects without using statins.
Key points to consider in this decision include:
- The patient's age and potential for polypharmacy, which may increase the risk of adverse effects (1)
- The presence of statin allergies, which limits treatment options and necessitates the use of non-statin therapies (1)
- The importance of considering the patient's overall health status, life expectancy, and goals of care when making treatment decisions (1)
- The potential benefits of PCSK9 inhibitors in reducing LDL levels and cardiovascular risk in patients with atherosclerotic cardiovascular disease (1)
In terms of specific treatment options, evolocumab and alirocumab are both FDA-approved for the treatment of primary hyperlipidemia and have been shown to be effective in reducing LDL levels and cardiovascular risk in patients with atherosclerotic cardiovascular disease (1). The choice between these two agents will depend on individual patient factors, including their specific lipid profile, medical history, and personal preferences.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Recommendations for an 88-Year-Old Patient with Allergies to Statins
The patient in question has an LDL level of 106 and a total cholesterol of 159, and is currently on ezetimibe 10 mg once daily. Given their allergies to statins, alternative treatment options must be considered.
- Current Treatment: The patient is already on ezetimibe, which is a reasonable choice for lowering LDL-C levels, especially in patients who cannot tolerate statins 2, 3.
- Additional Treatment Options: Other non-statin therapies that may be considered include bile acid sequestrants, fibrates, and PCSK9 inhibitors. However, the evidence for these therapies in reducing cardiovascular events is limited, and they may be considered on a case-by-case basis 3, 4.
- Considerations for Older Adults: In older adults, the importance of cholesterol as a risk factor is controversial, and the benefits of statins may be independent of cholesterol levels 5. However, ezetimibe has been shown to be effective in reducing LDL-C levels and may be a reasonable alternative to statins in this population.
- Monitoring and Follow-Up: Regular monitoring of the patient's lipid profiles and cardiovascular risk factors is essential to determine the effectiveness of the current treatment and to make any necessary adjustments.
Key Considerations
- The patient's allergies to statins limit the treatment options, and alternative therapies must be carefully considered.
- Ezetimibe is a reasonable choice for lowering LDL-C levels in patients who cannot tolerate statins.
- The evidence for non-statin therapies is limited, and treatment decisions should be made on a case-by-case basis.
- Regular monitoring and follow-up are essential to determine the effectiveness of the treatment and to make any necessary adjustments 2, 3, 6, 4.