From the Guidelines
Familial hypercholesterolemia (FH) is not a contraindication for most medications, but certain treatments require caution or avoidance due to their potential impact on lipid levels and cardiovascular risk. When considering medication management for patients with FH, it's essential to prioritize treatments that minimize cardiovascular risk.
- Estrogen-containing hormonal contraceptives and hormone replacement therapies should be used with caution or avoided in FH patients due to their potential to further increase lipid levels and cardiovascular risk 1.
- Some antipsychotics (like olanzapine and clozapine) and immunosuppressants (like cyclosporine) may exacerbate lipid abnormalities in FH patients and should be used cautiously with close monitoring.
- Conversely, FH patients often require aggressive lipid-lowering therapy, typically including high-intensity statins (atorvastatin 40-80mg or rosuvastatin 20-40mg daily), often combined with ezetimibe 10mg daily, as recommended by the 2022 ACC expert consensus decision pathway 1.
- For severe cases or those not reaching targets, PCSK9 inhibitors (evolocumab or alirocumab) may be added, as supported by recent studies 1. The most recent and highest quality study, published in 2022, provides guidance on the role of nonstatin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk, emphasizing the importance of personalized treatment approaches for patients with FH 1.
From the FDA Drug Label
Do not take ezetimibe tablets: if you are allergic to ezetimibe or any of the ingredients in ezetimibe tablets
- Contraindications for ezetimibe tablets include allergy to ezetimibe or its ingredients.
- There is no mention of familial hypercholesterolemia (FH) as a contraindication for ezetimibe tablets. In fact, ezetimibe tablets are used to treat heterozygous familial hypercholesterolemia (HeFH) and homozygous familial hypercholesterolemia (HoFH). 2
From the Research
Medication Considerations for Familial Hypercholesterolemia (FH)
- There is no evidence to suggest that FH is a contraindication for any specific medication 3, 4, 5, 6, 7.
- However, patients with FH may require higher doses of statins, more potent statins, statin-based combination therapy, or adjunctive therapies to achieve acceptable LDL-C levels 3.
- Certain medications, such as mipomersen and lomitapide, have been approved for use in patients with homozygous FH (HoFH) and may be considered for patients with severe hypercholesterolemia 3, 4, 6.
- PCSK9 inhibitors, such as alirocumab and evolocumab, have been shown to be effective in reducing LDL-C levels in patients with FH and may be considered as an emerging treatment option 4, 6, 7.
Key Considerations for Medication Use in FH
- The choice of medication and treatment approach should be individualized based on the patient's specific needs and medical history 3, 5, 6, 7.
- Combination therapy, including statins, ezetimibe, and other LDL-C-lowering agents, may be necessary to achieve optimal LDL-C levels 3, 4, 6.
- Regular monitoring of LDL-C levels and cardiovascular risk factors is essential to ensure effective management of FH 5, 6, 7.