From the Guidelines
The recommended treatment for elevated LDL cholesterol, given the patient's LDL level of 143 mg/dL, typically begins with lifestyle modifications, including a heart-healthy diet low in saturated fats, regular physical activity, weight management, and smoking cessation. If these measures are insufficient, statin medications are the first-line pharmacological treatment, as suggested by the most recent guidelines 1. Given the patient's age is not specified, but assuming an adult patient, the treatment approach would align with guidelines for adults. The patient's LDL level of 143 mg/dL is above the general guideline recommendations for individuals without high risk, which often suggest an LDL goal of less than 130 mg/dL for those with two or more risk factors, but the specific approach can depend on the patient's overall cardiovascular risk profile. For patients with very high LDL or established cardiovascular disease, higher intensity statins are recommended. If statins alone are inadequate or poorly tolerated, additional medications may be added. Treatment is typically lifelong, with regular monitoring of lipid levels and liver function. It's also important to consider the patient's other lipid values, such as triglycerides and HDL, in the context of their overall cardiovascular risk assessment. Given the information provided, lifestyle modifications should be initiated, and if the patient's LDL remains elevated after these changes, consideration of statin therapy would be appropriate, taking into account the patient's age, other risk factors, and the presence of any cardiovascular disease 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)
The recommended treatment for a patient with elevated Low-Density Lipoprotein (LDL) levels is ezetimibe tablets in combination with a statin, or alone when additional LDL-C lowering therapy is not possible, as an adjunct to diet to reduce elevated LDL-C. The dosage is 10-mg orally once daily, with or without food 2.
- Key considerations:
- Assess LDL-C when clinically appropriate, as early as 4 weeks after initiating ezetimibe tablets.
- Liver enzyme testing should be performed as clinically indicated and consider withdrawal of ezetimibe tablets if increases in ALT or AST ≥3 X ULN persist.
- Ezetimibe tablets may cause myopathy and rhabdomyolysis, so if myopathy is suspected, discontinue ezetimibe tablets and other concomitant medications, as appropriate.
From the Research
Elevated Low-Density Lipoprotein (LDL) Levels Treatment
The patient's fasting lab results show elevated LDL levels, with a calculated LDL of 143. According to the studies, the recommended treatment for elevated LDL levels includes:
- Statin therapy, which is the most potent drug for lowering LDL-C and is well tolerated in most patients 3
- Addition of ezetimibe, a cholesterol absorption inhibitor, to statin therapy, which leads to additional LDL-C reduction and decreased ASCVD risk 4, 3
- Use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, such as alirocumab and evolocumab, which significantly decrease serum LDL cholesterol levels and ASCVD risks when added to maximally tolerated statin therapy 5, 4
Treatment Goals
The goal of treatment is to achieve very low LDL-C levels, especially in individuals at highest risk, with a paradigm of "lower is better" 6. The studies suggest that:
- There is no lower limit for LDL-C, and large, randomized studies and meta-analyses have found continuous benefit and no safety concerns in patients achieving LDL-C levels <25 mg/dL 7
- Achieving population-level guideline-recommended reductions in LDL-C will require a collaborative effort from patients, clinicians, relevant professional societies, drug manufacturers, and payers 7
Barriers to Treatment
Despite the availability of effective treatments, many patients with elevated LDL levels do not achieve guideline-recommended reductions in LDL-C due to: