From the Guidelines
Lipoprotein(a) can be treated with antisense oligonucleotides like pelacarsen, which can reduce Lp(a) levels by up to 90% or more, as demonstrated in recent studies 1. The primary goal of treatment is to manage overall cardiovascular risk, as Lp(a) levels are largely genetically determined and challenging to modify. Several approaches can be used to treat Lp(a), including:
- Niacin (vitamin B3) at doses of 1-3 grams daily, which can reduce Lp(a) levels by 20-30% 2
- PCSK9 inhibitors like evolocumab (Repatha) and alirocumab (Praluent), given as injections every 2-4 weeks, can lower Lp(a) by 20-30% 3, 4
- LDL apheresis (a dialysis-like procedure that filters lipoproteins from blood) may be used for severe cases
- Lifestyle modifications such as maintaining a healthy weight, regular exercise, avoiding tobacco, and following a heart-healthy diet should accompany pharmaceutical interventions It's essential to note that statins are not effective for Lp(a) reduction specifically but are often prescribed alongside other treatments to manage overall cardiovascular risk 3, 4. The European Society of Cardiology (ESC) guidelines recommend measuring Lp(a) in patients at high risk of cardiovascular disease (CVD) and targeting levels below 50 mg/dL 3, 4. Emerging treatments like antisense oligonucleotides offer promising results, with pelacarsen reducing Lp(a) by up to 80% in clinical trials 1, 5. Overall, treatment focuses on managing overall cardiovascular risk rather than achieving specific Lp(a) targets, as Lp(a) levels are largely genetically determined and difficult to modify.
From the Research
Treatment Options for Lp(a)
- Lipoprotein apheresis (LA) has been shown to efficiently lower Lp(a) levels and reduce the risk of incident CV events 6.
- Statins have neutral or detrimental effects on Lp(a), while PCSK9 inhibitors can significantly reduce Lp(a) levels by up to 30% 6.
- Antisense oligonucleotides (ASO) have been found to specifically lower Lp(a) with good safety and strong efficacy, with reductions of up to 90% 6, 7, 8.
- Small interference RNAs (siRNAs) such as olpasiran are also being investigated for their potential to lower Lp(a) levels, with dose-dependent reductions of up to 90% 7, 8.
Management of Patients with Elevated Lp(a)
- Elevated Lp(a) increases cardiovascular risk and can be incorporated into existing risk stratification paradigms 9.
- The cornerstone of management is aggressive management of traditional cardiovascular risk factors, including LDL-cholesterol (LDL-C) 9.
- Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), aspirin in primary prevention, and prolonged dual antiplatelet therapy in secondary prevention may also be considered 9.
- Lp(a)-targeted therapies are being developed and may be available in the near future, but an elevated Lp(a) level is actionable today, and uncertainty regarding management should not be a barrier to testing 9, 8.