What is the recommended treatment for a patient with newly diagnosed hypercholesterolemia and COVID-19?

Management of Newly Diagnosed Hypercholesterolemia in COVID-19 Patients

Cholesterol-lowering drug therapies should be continued and optimized during COVID-19 infection, unless specifically contraindicated due to adverse drug interactions or abnormal liver function. 1

Initial Assessment and Treatment Approach

For Newly Diagnosed Hypercholesterolemia with COVID-19:

1. First-line therapy:

   • Start with maximally tolerated high-potency statins (atorvastatin, rosuvastatin, or pitavastatin) 1
   • Consider immediate addition of ezetimibe in patients with COVID-19 to achieve more aggressive LDL-C reduction 1
   • Implement a fat-modified, heart-healthy diet alongside medication 1

2. Monitoring parameters before initiating therapy:

   • Hepatic aminotransferases
   • Creatine kinase
   • Glucose/HbA1c
   • Creatinine 1

3. Follow-up monitoring:

   • Monitor hepatic aminotransferases in patients taking statins, especially those with history of liver disease or excess alcohol use
   • Check creatine kinase if musculoskeletal symptoms develop
   • Monitor glucose/HbA1c in patients with diabetes risk factors 1

Treatment Algorithm Based on COVID-19 Severity

Outpatient COVID-19 with Hypercholesterolemia:

• Initiate or continue statin therapy without interruption
• Add ezetimibe if LDL-C goals are not achieved 1
• Consider bempedoic acid as additional therapy if available 1

Hospitalized COVID-19 with Hypercholesterolemia:

• Continue lipid-lowering therapy during hospitalization 1
• Monitor liver function tests more frequently
• If liver function becomes abnormal, consider dose reduction rather than complete discontinuation 1
• For patients with extremely high cardiovascular risk, consider more aggressive combination therapy with statin, ezetimibe, and PCSK9 inhibitor 1

Special Considerations for COVID-19 Patients

1. Drug interactions:

   • Be aware of potential interactions between COVID-19 treatments and lipid-lowering medications
   • Consider switching from ticagrelor or clopidogrel to prasugrel if concerns exist for drug-drug interactions in patients requiring antiplatelet therapy 1

2. Cardiovascular sequelae of COVID-19:

   • Patients with cardiovascular complications from COVID-19 should be managed according to contemporary expert guidelines 1
   • For patients with COVID-19 and confirmed acute coronary syndrome, dual antiplatelet therapy is recommended 1

3. Vaccination recommendations:

   • All adult patients with hypercholesterolemia should be offered SARS-CoV-2, influenza, and pneumococcal vaccines as preventive measures against respiratory infections and acute cardiovascular events 1

Treatment Goals and Escalation

1. If LDL-C goals are not achieved with statin and ezetimibe:

   • Consider adding plant sterols (stanols) or bile acid sequestrants (colesevelam) 1
   • For patients not reaching goals despite maximally tolerated statins, ezetimibe, and other adjunctive therapies, add PCSK9-targeted therapy (monoclonal antibodies or inclisiran) 1

2. For extremely high-risk patients:

   • Consider first-line combination therapy with high-potency statin, ezetimibe, and PCSK9-targeted therapy 1
   • This applies particularly to patients with previous myocardial infarction, multivessel coronary atherosclerosis, or polyvascular disease 1

Common Pitfalls and Caveats

1. Avoid discontinuing lipid-lowering therapy during COVID-19:

   • Evidence suggests that statins may have beneficial effects in COVID-19 patients due to their anti-inflammatory and immunomodulatory properties 2
   • Discontinuing therapy may worsen cardiovascular outcomes 1

2. Monitor for hepatotoxicity:

   • COVID-19 can cause liver injury, which may be exacerbated by statins
   • Regular monitoring of liver function is essential, especially in hospitalized patients 1

3. Familial Hypercholesterolemia (FH) considerations:

   • FH patients may be at increased risk for COVID-19 complications due to pre-existing endothelial dysfunction 3
   • More aggressive LDL-C lowering may be warranted in FH patients with COVID-19 4
   • Consider early addition of PCSK9 inhibitors in FH patients with COVID-19, particularly those with elevated lipoprotein(a) 4

4. Avoid unnecessary treatment delays:

   • The pandemic should not delay initiation of appropriate lipid-lowering therapy in newly diagnosed hypercholesterolemia 5
   • Telehealth services can be utilized for initial consultation and follow-up monitoring 5

By following these recommendations, clinicians can effectively manage newly diagnosed hypercholesterolemia in patients with COVID-19, potentially improving both cardiovascular outcomes and COVID-19 prognosis.