Herbs Are Not Effective for Treating Familial Hypercholesterolemia
Herbs are not effective for treating Familial Hypercholesterolemia (FH) and should not be used in place of evidence-based medical therapies. FH requires aggressive lipid-lowering treatment with established pharmacological agents to reduce morbidity and mortality from premature atherosclerotic cardiovascular disease (ASCVD).
Standard of Care for FH Treatment
First-Line Therapy
- High-intensity statin therapy is the cornerstone of FH treatment, with the goal of achieving ≥50% LDL-C reduction from baseline 1, 2
- For patients with severe hypercholesterolemia (LDL-C ≥190 mg/dL), statins are the initial treatment of choice 1
- When LDL-C remains >100 mg/dL despite maximal tolerated statin therapy, additional LDL-C lowering medications should be added 1
Second-Line and Combination Therapy
- Ezetimibe should be added to statin therapy when LDL-C goals are not achieved 1, 2
- PCSK9 inhibitors (evolocumab, alirocumab) should be considered for patients who fail to achieve target LDL-C levels with maximally tolerated statin plus ezetimibe 1, 2
- Bile acid sequestrants (colesevelam) may be considered as an additional option, though they have limited tolerability 1, 2
Treatment Goals
- LDL-C targets should be based on ASCVD risk level 2:
- <100 mg/dL for patients with no ASCVD or major risk factors
- <70 mg/dL for patients with imaging evidence of ASCVD or major risk factors
- <55 mg/dL for patients with clinical ASCVD
- <40 mg/dL for patients with recurrent ASCVD events within 2 years on maximally tolerated statin
Why Herbs Are Not Recommended for FH
No evidence of efficacy: None of the major clinical guidelines for FH management recommend herbs for LDL-C reduction 1, 2
Severity of FH requires proven therapies: FH is characterized by severely elevated LDL-C levels (often >190 mg/dL) that significantly increase cardiovascular risk, requiring medications with established efficacy 1
Magnitude of LDL-C reduction needed: Patients with FH require substantial LDL-C reductions (≥50%) that cannot be achieved with herbal remedies 1
Risk of delayed effective treatment: Relying on herbs instead of established therapies may delay appropriate treatment, increasing the cumulative exposure to elevated LDL-C and atherosclerotic burden 2
Limited Role of Adjunctive Therapies
While some adjunctive therapies have been studied in FH patients, their effects are modest:
- Plant sterols/stanols may lower LDL-C but do not improve endothelial function in FH patients 1
- Antioxidant vitamins (C and E) may improve endothelial function in small studies, but long-term efficacy trials in adults have not shown cardiovascular benefit 1
- Docosahexaenoic acid supplementation has shown some improvement in endothelial function in small studies, but is not recommended as primary therapy 1
Special Considerations
Homozygous FH (HoFH)
- HoFH is a more severe form requiring even more aggressive therapy
- Combination of high-potency statin, ezetimibe, and PCSK9 inhibitors is often needed 1
- Lipoprotein apheresis, lomitapide, or evinacumab may be necessary in severe cases 1
- Liver transplantation may be considered for patients with rapidly progressive ASCVD who do not respond to other treatments 1
Children with FH
- Statin therapy is recommended as first-line treatment for children meeting criteria for lipid-lowering drug therapy 1
- Treatment goals for children: LDL-C <130 mg/dL (minimal) or <110 mg/dL (ideal) 1
Monitoring and Follow-up
- Baseline liver enzymes, creatine kinase, glucose, and creatinine should be measured before starting therapy 2
- Monitor liver enzymes in patients taking statins, particularly those with risk factors for hepatotoxicity 2
- Check creatine kinase if musculoskeletal symptoms develop 2
In conclusion, FH is a serious genetic disorder requiring evidence-based medical therapies to reduce cardiovascular morbidity and mortality. Herbs have no established role in FH management and should not be used in place of proven pharmacological treatments.