From the Guidelines
PSCK9 inhibitors should be initiated for dyslipidemia management when patients have not achieved LDL-C goals despite maximally tolerated statin therapy plus ezetimibe, particularly in high-risk individuals, such as those with atherosclerotic cardiovascular disease (ASCVD), familial hypercholesterolemia, or those with very high LDL-C levels (>190 mg/dL) 1.
Key Considerations
- High-risk groups include patients with ASCVD, familial hypercholesterolemia, or those with very high LDL-C levels (>190 mg/dL) 1.
- PCSK9 inhibitors are also appropriate for patients who cannot tolerate statins due to side effects like myopathy.
- Typical dosing includes evolocumab 140 mg subcutaneously every 2 weeks or 420 mg monthly, or alirocumab 75-150 mg subcutaneously every 2 weeks.
- Before initiating therapy, confirm that the patient has truly maximized other lipid-lowering options and verify insurance coverage, as these medications can be expensive.
Mechanism and Efficacy
- PCSK9 inhibitors work by preventing the degradation of LDL receptors on liver cells, allowing more receptors to remain active and remove LDL cholesterol from the bloodstream.
- This mechanism results in substantial LDL-C reductions of 50-70%, beyond what can be achieved with statins and ezetimibe alone 1.
Clinical Guidelines
- The 2018 American Heart Association/American College of Cardiology/Multisociety Cholesterol Guideline recommends adding a nonstatin medication (ezetimibe or PCSK9 inhibitors) to maximally tolerated statin therapy in patients with very high-risk ASCVD and an LDL-C level of 1.8 mmol/L (70 mg/dL) or higher 1.
- In patients at very high risk whose LDL-C levels remain above this threshold while they receive maximally tolerated statin and ezetimibe therapy, the guideline suggests that a PCSK9 inhibitor is a reasonable addition, although long-term safety (>3 years) is uncertain and cost-effectiveness was low at mid-2018 list prices 1.
From the FDA Drug Label
To reduce the risk of myocardial infarction, stroke, and unstable angina requiring hospitalization in adults with established cardiovascular disease (1) As adjunct to diet, alone or in combination with other low-density lipoprotein cholesterol (LDL-C)-lowering therapies, in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH), to reduce LDL-C. (1) The recommended starting dosage of PRALUENT is either 75 mg once every 2 weeks or 300 mg once every 4 weeks administered subcutaneously.
Initiation of PCSK9 Inhibitor:
- A PCSK9 inhibitor, such as alirocumab, can be initiated in adults with established cardiovascular disease to reduce the risk of myocardial infarction, stroke, and unstable angina requiring hospitalization.
- It can also be initiated in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH), as an adjunct to diet and other LDL-C-lowering therapies to reduce LDL-C.
- The recommended starting dosage is either 75 mg once every 2 weeks or 300 mg once every 4 weeks administered subcutaneously 2.
From the Research
Initiating PSK9 Inhibitors for Dyslipidemia Management
- The decision to initiate a PSK9 inhibitor for dyslipidemia management should be based on the patient's cardiovascular risk and their response to other lipid-lowering therapies 3, 4, 5.
- Patients with a history of myocardial infarction or ischemic stroke may benefit from PSK9 inhibitors, as they have been shown to reduce the risk of major cardiovascular events in these patients 3, 4.
- The 2018 Cholesterol Guideline recommends the use of PSK9 inhibitors in select secondary prevention patients who are unable to achieve an LDL-C level below 70 mg/dL despite maximally tolerated statin plus ezetimibe therapy 5.
- PSK9 inhibitors, such as alirocumab and evolocumab, have been shown to be effective in reducing LDL-C levels by up to 60% and are relatively safe, with the exception of injection site reactions 3, 4, 5.
- Emerging oral therapeutic strategies for inhibiting PSK9, such as small chemical molecules and mimetic peptides, are currently under clinical development and may provide a more cost-effective and convenient alternative to subcutaneous administration of monoclonal antibodies 6, 7.
Patient Selection
- Patients with atherosclerotic cardiovascular disease (ASCVD) and elevated LDL-C levels despite statin therapy may be candidates for PSK9 inhibitors 5.
- Patients with a history of myocardial infarction or ischemic stroke and elevated LDL-C levels may also benefit from PSK9 inhibitors 3, 4.
- The decision to initiate a PSK9 inhibitor should be based on a thorough assessment of the patient's cardiovascular risk and their potential to benefit from therapy 3, 4, 5.