From the Guidelines
Elevated cholesterol is best treated through a combination of lifestyle modifications and medication when necessary, with statins being the primary pharmacological treatment, as recommended by the European Society of Cardiology in 2020 1.
Lifestyle Modifications
Key lifestyle changes include:
- Adopting a heart-healthy diet low in saturated fats and trans fats, high in fiber, fruits, vegetables, and lean proteins
- Regular exercise, aiming for 150 minutes of moderate activity weekly
- Weight management
- Smoking cessation
- Limiting alcohol consumption
Medication
If lifestyle modifications are insufficient, statins are typically the first-line medication, including:
- Atorvastatin (10-80mg daily)
- Rosuvastatin (5-40mg daily)
- Simvastatin (10-40mg daily) For those who cannot tolerate statins, alternatives include:
- Ezetimibe (10mg daily)
- PCSK9 inhibitors (evolocumab or alirocumab)
- Bile acid sequestrants Treatment targets depend on individual cardiovascular risk, with higher-risk patients aiming for lower LDL levels, as supported by the American College of Cardiology Foundation/American Heart Association in 2011 1.
Monitoring and Adjustment
Regular monitoring through lipid panels every 3-6 months initially, then annually once stable, helps ensure treatment effectiveness and detect potential side effects early. The choice of statin may be influenced by its anti-inflammatory effects, with atorvastatin or rosuvastatin being potentially beneficial in certain cases, such as rheumatoid arthritis, as noted in the European Heart Journal in 2020 1.
From the FDA Drug Label
EZETIMIBE Tablets is indicated (1): • In combination with a statin, or alone when additional low density lipoprotein cholesterol (LDL-C) lowering therapy is not possible, as an adjunct to diet to reduce elevated LDL-C in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH) • In combination with a statin as an adjunct to diet to reduce elevated LDL-C in pediatric patients 10 years of age and older with HeFH. • In combination with fenofibrate as an adjunct to diet to reduce elevated LDL-C in adults with mixed hyperlipidemia • In combination with a statin, and other LDL-C lowering therapies, to reduce elevated LDL-C levels in adults and in pediatric patients 10 years of age and older with homozygous familial hypercholesterolemia (HoFH)
Ezetimibe is used to treat elevated cholesterol by reducing low-density lipoprotein cholesterol (LDL-C) levels. The recommended dosage is 10 mg orally once daily, with or without food. Ezetimibe can be used alone or in combination with other medications, such as statins or fenofibrate, to reduce LDL-C levels in adults and pediatric patients with various types of hyperlipidemia, including primary hyperlipidemia, heterozygous familial hypercholesterolemia (HeFH), mixed hyperlipidemia, and homozygous familial hypercholesterolemia (HoFH) 2.
From the Research
Elevated Cholesterol Treatment Options
- Lifestyle approaches are recommended as the first line of therapy for patients with mildly or moderately elevated blood pressure and cholesterol, as stated by the American Heart Association and the American College of Cardiology 3.
- Increasing physical activity has extensive benefits, including improving both blood pressure and blood cholesterol, and is a recommended lifestyle change for patients with elevated cholesterol 3.
Medication Treatment Options
- For high-risk patients with hypercholesterolemia, statin monotherapy is often insufficient to achieve target low-density lipoprotein cholesterol (LDL-C) levels, and second-line treatment options include up-titration of statin dose, switching to a more potent statin, or combination therapy with ezetimibe 4.
- The addition of ezetimibe to ongoing simvastatin, atorvastatin, or rosuvastatin monotherapy offers greater reduction in LDL-C among patients at high risk of cardiovascular disease compared to doubling the initial statin dose 4.
- Co-administration of ezetimibe and statins significantly decreases plasma levels of non-cholesterol sterols, consistent with net inhibition of sterol absorption and cholesterol synthesis 5.
Other Considerations
- The potential influence of treatment-induced changes in phytosterols on cardiovascular risk warrants further investigation in long-term, prospective, randomized controlled trials 5.
- Note that some studies may not be directly relevant to elevated cholesterol treatment, such as those focused on cardiac insufficiency or vasodilators 6.