From the Guidelines
To lower apolipoprotein B (apoB) levels, a combination of medications and lifestyle changes is recommended, with a target apoB level of <80 mg/dL for very high CV risk and <100 mg/dL for high CV risk, as suggested by the most recent guidelines 1. The first-line medication for lowering apoB is statins, with high-intensity options like atorvastatin (40-80mg daily) or rosuvastatin (20-40mg daily) being most effective at reducing apoB by 30-50% 1. If statins alone are insufficient, adding ezetimibe (10mg daily) can further reduce apoB by 10-15% 1. For patients with very high apoB or those with familial hypercholesterolemia, PCSK9 inhibitors like evolocumab (140mg every 2 weeks) or alirocumab (75-150mg every 2 weeks) can lower apoB by an additional 50-60% 1. Lifestyle modifications are equally important and include:
- Adopting a Mediterranean or DASH diet rich in fruits, vegetables, whole grains, and lean proteins while limiting saturated fats, trans fats, and refined carbohydrates 2
- Regular physical activity (at least 150 minutes of moderate-intensity exercise weekly) 2
- Weight management targeting a BMI under 25 2
- Smoking cessation 2
- Limiting alcohol consumption to moderate levels 2 These interventions work by reducing the production of apoB-containing lipoproteins in the liver and enhancing their clearance from circulation, thereby lowering cardiovascular risk since apoB represents the total number of atherogenic particles in the bloodstream 3. The goal of therapy should be to reduce LDL-C levels by at least 50% from baseline or reach the individual’s risk-based goal, whichever is lower, with a target LDL-C level of <1.8 mmol/L (less than 70 mg/dL) for very high CV risk and <2.5 mmol/L (less than 100 mg/dL) for high CV risk 3. It is essential to note that the choice of medication and lifestyle modifications should be individualized based on the patient's risk factors, comorbidities, and response to therapy, with regular monitoring of apoB and LDL-C levels to adjust treatment as needed 1.
From the FDA Drug Label
Ezetimibe Tablet reduces total-C, LDL-C, Apo B, and non-HDL-C in patients with hyperlipidemia. In two multicenter, double-blind, placebo-controlled, 12-week trials in 1719 patients with primary hyperlipidemia, ezetimibe tablet significantly lowered total-C, LDL-C, Apo B, and non-HDL-C compared to placebo. Ezetimibe Tablet, added to on-going statin therapy, significantly lowered total-C, LDL-C, Apo B, and non-HDL-C compared with a statin administered alone.
Medications that lower apoB:
- Ezetimibe
- Statins (such as atorvastatin, simvastatin, pravastatin, lovastatin)
Lifestyle changes that can help lower apoB:
- No specific lifestyle changes are mentioned in the provided drug labels.
From the Research
Lowering apoB through Medication
- Statins have been shown to reduce plasma apoB levels, with a relative risk of 0.92 for all-cause mortality and 0.88 for major adverse cardiovascular events (MACE) per 10 mg/dL decrease in apoB 6
- Ezetimibe, which blocks cholesterol absorption, has also been found to lower apoB levels, with a reduction in MACE and stroke risk 7, 8
- Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to reduce apoB levels and cardiovascular risk, particularly when used in combination with statins and ezetimibe 7, 8
Lowering apoB through Lifestyle Changes
- Dietary changes, such as a Mediterranean dietary pattern, have been found to reduce plasma apoB levels and cardiovascular risk 9
- Specific dietary components, including:
- Weight loss of 6-12% through hypoenergetic diets has also been shown to reduce apoB levels 9
Combination Therapy
- Combining medication and lifestyle changes may be more effective in lowering apoB levels and reducing cardiovascular risk than either approach alone 9, 7, 8
- The use of PCSK9 inhibitors in combination with statins and ezetimibe may provide additional benefits in reducing apoB levels and cardiovascular risk 7, 8