From the Guidelines
Alternative medications for managing hypercholesterolemia include PCSK9 inhibitors, ezetimibe, bile acid sequestrants, and bempedoic acid, which can be considered for patients who cannot tolerate statins or require additional LDL reduction. When managing hypercholesterolemia, particularly in patients with severe hypercholesterolemia (LDL-C ≥190 mg/dL), the primary goal is to reduce LDL-C levels to minimize the risk of cardiovascular events 1. According to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol, maximally tolerated statin therapy is recommended as the first-line treatment for patients with LDL-C levels ≥190 mg/dL 1. However, for patients who achieve less than a 50% reduction in LDL-C while receiving maximally tolerated statin therapy, ezetimibe therapy is reasonable, as it can reduce LDL-C levels by an additional 15-20% 1. Other alternative medications, such as bile acid sequestrants and PCSK9 inhibitors, may be considered for patients who require further LDL reduction, particularly those with heterozygous familial hypercholesterolemia (HeFH) or those who have not achieved adequate LDL-C reduction with statin and ezetimibe therapy 1. Some key points to consider when selecting alternative medications for hypercholesterolemia include:
- PCSK9 inhibitors, such as evolocumab and alirocumab, can lower LDL-C levels by 50-70% and are typically reserved for patients with HeFH or those who require significant LDL reduction 1
- Ezetimibe can reduce LDL-C levels by 15-20% and is often used in combination with statin therapy 1
- Bile acid sequestrants, such as cholestyramine and colesevelam, can lower LDL-C levels by 10-20% and may be considered for patients who cannot tolerate other medications 1
- Bempedoic acid, a newer medication, works in the liver to block cholesterol production and can reduce LDL-C levels by 15-25% 1. Ultimately, the choice of alternative medication for hypercholesterolemia depends on the patient's specific cholesterol profile, medical history, and the degree of LDL reduction needed to reach target levels, as well as their ability to tolerate the medication 1.
From the Research
Alternative Medications for Managing Hypercholesterolemia
Alternative medications for managing hypercholesterolemia include:
- Ezetimibe: a cholesterol absorption inhibitor that can be used alone or in combination with statins to lower LDL-cholesterol levels 2, 3, 4, 5, 6
- Evolocumab: a proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody that can reduce LDL-cholesterol levels by 53% to 56% 3, 4
- Rosuvastatin: a statin that can be used in combination with ezetimibe to lower LDL-cholesterol levels and reduce cardiovascular risk 6
Combination Therapies
Combination therapies, such as ezetimibe and statins, or ezetimibe and PCSK9 inhibitors, can be effective in lowering LDL-cholesterol levels and reducing cardiovascular risk 3, 4, 5, 6
- Ezetimibe and statin combination therapy can lower LDL-cholesterol levels by an additional 25% compared to statin monotherapy 2, 5
- Ezetimibe and PCSK9 inhibitor combination therapy can lower LDL-cholesterol levels by 53% to 56% 3
Safety and Efficacy
The safety and efficacy of these alternative medications and combination therapies have been established in several studies:
- Ezetimibe has a favorable pharmacokinetic profile and a safety profile comparable to placebo 2
- Ezetimibe and statin combination therapy is generally safe and effective in lowering LDL-cholesterol levels and reducing cardiovascular risk 5, 6
- Evolocumab has been shown to be effective in lowering LDL-cholesterol levels, but may have a higher cost and risk of adverse events such as injection site reactions 3, 4