How to manage hypercholesterolemia with a total cholesterol level of 7.5 mmol/L?

From the Guidelines

A total cholesterol level of 7.5 mmol/L requires immediate management through lifestyle modifications and possibly medication to reduce the risk of atherosclerotic cardiovascular disease (ASCVD) 1. To manage a total cholesterol level of 7.5 mmol/L, the following steps should be taken:

• Emphasize a heart-healthy lifestyle, including a diet low in saturated fats and trans fats, and high in fruits, vegetables, whole grains, lean proteins, and healthy fats like olive oil and nuts 1.
• Engage in regular physical activity, aiming for at least 150 minutes of moderate exercise weekly.
• Maintain a healthy weight, quit smoking if applicable, and limit alcohol consumption.
• If lifestyle changes are insufficient, consider medication, with statins being the first-line treatment option 1.
• The choice of statin and dosage will depend on individual risk factors and ASCVD risk, with options including atorvastatin, rosuvastatin, or simvastatin 1. Key considerations in managing high cholesterol include:
• Reducing low-density lipoprotein cholesterol (LDL-C) levels, with a goal of lowering LDL-C by 50% in patients with clinical ASCVD 1.
• Using a maximally tolerated statin to achieve this goal, and considering the addition of non-statins, such as ezetimibe, in very high-risk patients 1.
• Regular follow-up with a healthcare provider to monitor cholesterol levels and adjust treatment as needed 1.

From the FDA Drug Label

The effects of simvastatin on total-C and LDL-C were assessed in controlled clinical studies in adult patients with heterozygous familial and non-familial forms of hyperlipidemia and in mixed hyperlipidemia. simvastatin significantly decreased total-C, LDL-C, and TG, and increased HDL-C Maximal to near maximal response was generally achieved within 4-6 weeks and maintained during chronic therapy

To manage a total cholesterol level of 7.5, simvastatin can be considered as a treatment option. The dosage of simvastatin can be started at 10-20 mg once daily and titrated up to 40-80 mg once daily, depending on the patient's response and tolerance.

• It is essential to monitor the patient's lipid profile, liver enzymes, and other vital signs regularly while on simvastatin therapy.
• The patient should also be advised to follow a healthy diet and lifestyle modifications, such as regular exercise, weight management, and smoking cessation, to help lower their cholesterol levels.
• It is also important to note that simvastatin can be used in combination with other lipid-lowering therapies, such as ezetimibe, to achieve better control of cholesterol levels 2 3.

From the Research

Managing Total Cholesterol of 7.5

To manage a total cholesterol level of 7.5, several treatment options are available, including:

• Statins, which are the mainstay treatment for hyperlipidemia 4
• Adjunct therapies such as niacin, bile acid sequestrants, fibric acids, and ezetimibe 4
• Combination therapy with statin and another lipid-modifying agent, which may be an alternative for patients who do not tolerate or respond to high-intensity statin monotherapy 5

Treatment Options

The following treatment options may be considered:

• Statins, which are the most potent drugs for lowering low-density lipoprotein cholesterol (LDL-C) and are well tolerated in most patients 6
• Ezetimibe, which remains a very important combination partner for statins and has continuously increasing treatment numbers 7
• Bempedoic acid, which is another interesting combination partner for statin/ezetimibe or ezetimibe alone, but lacks evidence from outcome trials 7
• Bile acid sequestrants, such as colesevelam, which have additive cholesterol-lowering effects when used in combination with other lipid-lowering therapies 8

Combination Therapy

Combination therapy with statin and another lipid-modifying agent may be considered for patients who do not achieve LDL-C goals with statin monotherapy or who are intolerant of or unresponsive to statins. The following combinations may be considered:

• Statin plus bile acid sequestrant, which decreases LDL cholesterol level 0% to 14% more than mid-intensity monotherapy among high-risk hyperlipidemic patients 5
• Statin plus ezetimibe, which decreases LDL cholesterol level 5% to 15% and 3% to 21% more than high-intensity monotherapy among patients with atherosclerotic cardiovascular disease (ASCVD) and diabetes mellitus, respectively 5