From the Guidelines
To decrease apolipoprotein B (apoB) levels, focus on both lifestyle changes and possibly medication, with the goal of achieving an apoB level of <80 mg/dL for those at very high CV risk and <100 mg/dL for those at high CV risk, as recommended by the ESC/EAS guidelines 1.
Lifestyle Changes
- Adopt a Mediterranean-style diet rich in fruits, vegetables, whole grains, nuts, olive oil, and fatty fish while limiting saturated fats, trans fats, and refined carbohydrates.
- Regular exercise, aiming for 150 minutes of moderate activity weekly, can significantly reduce apoB levels.
- Weight loss, if overweight, and avoiding smoking and excessive alcohol are also crucial.
Medications
- Statins are first-line therapy, with high-intensity options like atorvastatin (40-80mg daily) or rosuvastatin (20-40mg daily) being most effective, as supported by the 2022 ACC expert consensus decision pathway 1.
- If statins alone are insufficient, ezetimibe (10mg daily) can be added.
- For those with persistently high levels, PCSK9 inhibitors like evolocumab or alirocumab may be prescribed as injections every 2-4 weeks.
- Bempedoic acid (180mg daily) is another option for statin-intolerant patients.
Key Considerations
- ApoB is a better predictor of cardiovascular risk than LDL cholesterol alone because it represents the total number of atherogenic particles in your bloodstream, with each apoB-containing lipoprotein capable of infiltrating arterial walls and contributing to atherosclerosis.
- The treatment targets for apoB are <80 mg/dL and <100 mg/dL in those at very high and high total CV risk, respectively, as recommended by the ESC/EAS guidelines 1.
- Clinicians should exercise judgement to avoid premature or unnecessary implementation of lipid-lowering therapy, considering the long-term effects of pharmacotherapy and potential side effects 1.
From the FDA Drug Label
In a 26-week controlled study in pediatric patients with HeFH (ages 10 years to 17 years) (n=140,31% female; 92% White, 1. 6% Black or African American, 1.6% Asian, 4.8% other), the safety and tolerability profile of atorvastatin calcium 10 to 20 mg daily, as an adjunct to diet to reduce total cholesterol, LDL-C, and apo B levels, was generally similar to that of placebo
Decreasing Apolipoprotein B (ApoB) levels can be achieved with atorvastatin calcium, as it has been shown to reduce apo B levels in clinical studies, specifically in pediatric patients with HeFH.
- The use of atorvastatin calcium 10 to 20 mg daily, as an adjunct to diet, has been found to reduce apo B levels. 2
From the Research
Decreasing Apolipoprotein B (ApoB) Levels
To decrease Apolipoprotein B (ApoB) levels, several dietary and therapeutic approaches can be considered. The following methods have been supported by research studies:
- Dietary Changes:
- Weight loss of 6-12% using hypoenergetic diets can reduce plasma ApoB levels 3.
- Diets composed of 26-51% carbohydrates, 26-46% fat, 11-32% protein, 10-27% monounsaturated fatty acids (MUFA), 5-14% polyunsaturated fatty acids (PUFA), and 7-13% saturated fatty acids (SFA) can decrease plasma ApoB 3.
- Replacement of carbohydrate by MUFA, not SFA, can decrease plasma ApoB 3.
- Dietary enrichment with n-3 fatty acids, psyllium, phytosterols, or nuts can also decrease plasma ApoB 3.
- Therapeutic Interventions:
- Statin therapy can alter the relationship between ApoB and low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) targets in high-risk patients 4.
- Reducing ApoB levels through various lipid-lowering therapies, including statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, and bile acid sequestrants, can decrease cardiovascular risk 5.
- Natural Products and Nutraceuticals:
- Certain natural products and nutraceuticals, such as medicinal plants and functional foods, may have a beneficial effect on plasma ApoB concentrations 6.
- Other Factors: