From the Guidelines
Treatment for hypercholesterolemia should prioritize statin therapy as the first-line approach, aiming for an LDL-C goal of < 1.8 mmol/L (70 mg/dL) for very high-risk individuals or a reduction of at least 50% if the baseline LDL-C is between 1.8 and 3.5 mmol/L (70 and 135 mg/dL), as recommended by the 2016 ESC/EAS guidelines 1.
Key Considerations
- The primary lipid analysis for screening, risk estimation, diagnosis, and management should be LDL-Cholesterol (LDL-C) 1.
- Statins are the primary medication choice, including atorvastatin (10-80 mg daily), rosuvastatin (5-40 mg daily), or simvastatin (10-40 mg daily), which work by inhibiting HMG-CoA reductase, reducing liver cholesterol production 1.
- For patients who cannot tolerate statins or need additional therapy, options include ezetimibe (10 mg daily), which blocks intestinal cholesterol absorption; PCSK9 inhibitors like evolocumab or alirocumab for severe cases; bile acid sequestrants; or fibrates 1.
- Treatment goals typically aim for LDL cholesterol below 100 mg/dL for most patients, or below 70 mg/dL for those with established cardiovascular disease 1.
Lifestyle Modifications
- Dietary changes such as reducing saturated fat and cholesterol intake, increasing fiber consumption, and maintaining a healthy weight are essential 1.
- Regular physical activity of at least 150 minutes per week is also crucial 1.
Monitoring and Follow-Up
- Regular monitoring of lipid levels and liver function is important, with follow-up testing recommended 4-12 weeks after starting therapy and periodically thereafter to assess efficacy and monitor for side effects 1.
Special Considerations
- Patients with very high triglycerides should not consume alcohol, and the use of bile acid sequestrants is relatively contraindicated when triglycerides are greater than 200 mg per dL 1.
- Pregnant and lactating women should limit their intake of fish to minimize exposure to methylmercury 1.
From the FDA Drug Label
Atorvastatin calcium tablets are an HMG-CoA reductase inhibitor (statin) indicated ... As an adjunct to diet to reduce low-density lipoprotein (LDL-C) in: Adults with primary hyperlipidemia
- Treatment for hypercholesterolemia: Atorvastatin can be used as an adjunct to diet to reduce LDL-C in adults with primary hyperlipidemia 2
From the Research
Treatment Options for Hypercholesterolemia
- Statins are the most potent drugs for lowering low-density lipoprotein cholesterol (LDL-C) levels and are well tolerated in most patients 3.
- The addition of a bile acid sequestrant or ezetimibe to a statin produces additional LDL-C reduction, allowing many patients to reach LDL-C targets 3, 4.
- Ezetimibe remains a very important combination partner for statins, with continuously increasing treatment numbers 5.
- Bempedoic acid is another interesting combination partner for statin/ezetimibe or ezetimibe alone, but lacks evidence from outcome trials 5.
- Fibrates may still be used in selected, high-risk patients with combined dyslipidemia, but have shown disappointing results in outcome trials 5.
- Bile acid sequestrants are now rarely used as there are stronger, better tolerable ways to lower LDL-cholesterol 5.
Management of Hypercholesterolemia
- Pharmacotherapy is helpful in maintaining control of modifiable risk factors such as elevated lipids or hypercholesterolemia 6.
- Statin therapy has long been a mainstay in the treatment of hypercholesterolemia, but may have side effects that lead to patient noncompliance 6.
- New treatment options are being developed to manage hypercholesterolemia, including injectable lipid-lowering drugs 6, 5.
- Screening for heterozygous familial hypercholesterolemia, a common genetic disease of lipid metabolism, is important in primary prevention 7.
- Defining the threshold for therapeutic intervention and expected benefits is crucial in managing hypercholesterolemia 7.