What is the diagnosis and treatment for hypercholesterolemia (elevated cholesterol levels)?

From the Guidelines

Hypercholesterolemia should be managed with statins as the first-line treatment, aiming for an LDL-C goal of < 1.8 mmol/L (70 mg/dL) in patients at very high CV risk, 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), with HDL-C considered an independent risk factor 1.
• For patients at high CV risk, an LDL-C goal of < 2.6 mmol/L (100 mg/dL) is recommended, or a reduction of at least 50% if the baseline LDL-C is between 2.6 and 5.1 mmol/L (100 and 200 mg/dL) 1.
• Statins should be used up to the highest recommended dose or highest tolerable dose to reach the LDL-C goal, with options including atorvastatin, rosuvastatin, or simvastatin 1.
• In addition to statins, other treatments such as ezetimibe, PCSK9 inhibitors, or bile acid sequestrants may be considered for patients who cannot tolerate statins or need additional cholesterol lowering, as outlined in the 2022 ACC expert consensus decision pathway 1.

Management Approach

• Initial management includes adopting a heart-healthy diet and lifestyle modifications, with medication added when necessary.
• Regular physical activity, weight management, and smoking cessation are essential components of hypercholesterolemia management.
• Lipoprotein(a) [Lp(a)] levels should be measured in patients at high risk of cardiovascular disease, with a target level below 50 mg/dL, as recommended by the European Society of Cardiology guidelines.
• Regular lipid panel monitoring (every 3-12 months) is necessary to assess treatment effectiveness and adjust therapy as needed.

From the FDA Drug Label

If as dose is missed, take the missed dose as soon as possible. Do not double the next dose. Assess LDL-C when clinically appropriate, as early as 4 weeks after initiating ezetimibe tablets.

1. 1 Clinical Trials Experience ... 2,396 patients with primary hyperlipidemia (age range 9 to 86 years; 50% female, 90% White, 5% Black or African American, 2% Asian, 3% other races; 3% identified as Hispanic or Latino ethnicity) and elevated LDL-C were treated with ezetimibe tablets 10 mg daily for a median treatment duration of 12 weeks (range 0 to 39 weeks)

Ezetimibe is used to treat primary hyperlipidemia and elevated LDL-C, which are related to hypercholesterolemia.

• The medication is administered to patients with elevated LDL-C.
• LDL-C levels are assessed when clinically appropriate, as early as 4 weeks after initiating ezetimibe tablets.
• Ezetimibe tablets are used in patients with primary hyperlipidemia and elevated LDL-C 2.

From the Research

Hypercholesterolemia Treatment

• Hypercholesterolemia, especially LDL-C, is a major cardiovascular risk factor, especially for coronary artery disease 3.
• Patients at high or very high cardiovascular risk should reach LDL concentrations as low as possible, with a reduction of at least 50% from baseline levels according to the most recent guidelines 3.

First-Line Treatment

• For patients with mildly or moderately elevated blood pressure and blood cholesterol, lifestyle-only approaches are the first line of therapy 4.
• Increasing physical activity has extensive benefits, including improving both blood pressure and blood cholesterol, that are comparable, superior, or complementary to other healthy lifestyle changes 4.

Ezetimibe-Statin Combination Therapy

• An ezetimibe-statin combination most often allows to reach the goal of reducing LDL-C levels thanks to a complementary action 3.
• Ezetimibe/simvastatin combination therapy is more effective than statin monotherapy for reducing LDL-C levels and achieving therapeutic goals 5, 6, 7.
• The addition of ezetimibe to current statin therapy is more effective than doubling the statin dose 7.

Safety and Efficacy

• Ezetimibe/simvastatin combination therapy is generally well tolerated and provides significantly greater improvements in key lipid parameters and higher attainment of LDL cholesterol targets than atorvastatin 6.
• Ezetimibe/simvastatin therapy is an effective and generally well tolerated adjunct to dietary therapy for markedly reducing LDL-C levels and improving other lipid parameters across diverse patient populations 7.