What is the best treatment approach for a patient with high cholesterol who is intolerant to statins (HMG-CoA reductase inhibitors)?

Treatment of High Cholesterol in Statin-Intolerant Patients

For statin-intolerant patients with high cholesterol, initiate ezetimibe 10 mg daily as first-line therapy, then add bempedoic acid 180 mg daily if LDL-C targets are not met, and reserve PCSK9 inhibitors for very high-risk patients with persistent LDL-C elevation despite combination therapy. 1, 2

Defining Statin Intolerance

Before proceeding with alternative therapies, confirm true statin intolerance:

• The patient must have attempted at least 2 different statins, including at least one at the lowest approved daily dose 2
• Adverse effects should resolve or improve with dose reduction or discontinuation 2
• This distinction is critical because many patients labeled as "statin intolerant" can actually tolerate lower doses or different statins 1

First-Line Therapy: Ezetimibe

Start with ezetimibe 10 mg daily as the initial non-statin therapy for all statin-intolerant patients. 1, 2

• Ezetimibe reduces LDL-C by approximately 15-20% as monotherapy 2, 3
• It has excellent tolerability with minimal side effects, making it ideal for statin-intolerant patients 3, 4
• The ESC/EAS guidelines provide a Class I recommendation for ezetimibe as second-line therapy 1
• The BMJ guideline suggests ezetimibe in preference to PCSK9 inhibitors as initial non-statin therapy due to lower cost and established long-term safety data 1

Second-Line Therapy: Bempedoic Acid

If LDL-C targets are not achieved with ezetimibe alone after 4-8 weeks, add bempedoic acid 180 mg daily. 1, 2

• Bempedoic acid reduces LDL-C by an additional 15-25% when added to ezetimibe 1, 2
• The combination of ezetimibe plus bempedoic acid achieves approximately 35% total LDL-C reduction 1, 2
• Bempedoic acid is particularly valuable for statin-intolerant patients because it is activated only in the liver (not muscle cells), resulting in low rates of muscle-related adverse effects 1, 2
• The CLEAR Outcomes trial demonstrated a 13% reduction in major adverse cardiovascular events in statin-intolerant patients 2
• A fixed-dose combination of bempedoic acid 180 mg with ezetimibe 10 mg is FDA-approved and can simplify the regimen 1

Important caveat: Monitor liver function tests when using bempedoic acid, as slight elevations in ALT may occur 1

Third-Line Therapy: PCSK9 Inhibitors

Reserve PCSK9 inhibitors (evolocumab, alirocumab, or inclisiran) for very high-risk patients who remain above LDL-C targets despite ezetimibe plus bempedoic acid. 1, 2

When to Add PCSK9 Inhibitors:

Very high-risk patients (established ASCVD, recurrent events):

• Add PCSK9 inhibitor if LDL-C remains ≥70 mg/dL despite ezetimibe plus bempedoic acid 1, 2
• Target LDL-C <55 mg/dL with ≥50% reduction from baseline 1, 2
• ESC/EAS provides Class I recommendation for secondary prevention 1

High-risk patients (diabetes with complications, multiple risk factors):

• Consider PCSK9 inhibitor if LDL-C remains ≥100 mg/dL despite combination therapy 1, 2
• Target LDL-C <70 mg/dL 1, 2

Primary prevention patients:

• PCSK9 inhibitors have a weaker evidence base (Class IIb recommendation) 1
• Generally not recommended unless baseline LDL-C ≥190 mg/dL or familial hypercholesterolemia 2

PCSK9 Inhibitor Efficacy and Safety:

• PCSK9 inhibitors reduce LDL-C by approximately 50-60% 1, 2
• They are well-tolerated in statin-intolerant patients with minimal muscle-related adverse effects 2, 5
• NICE 2019 guidelines approve their use in statin-intolerant patients with primary hypercholesterolemia who fail to meet LDL-C targets 1

Critical consideration: The ACC/AHA guidelines provide only Class IIa recommendations for PCSK9 inhibitors (not Class I), reflecting their high cost and the recommendation to try ezetimibe and bempedoic acid first 1, 2

Alternative Options for Specific Scenarios

Bile Acid Sequestrants (Fourth-Line):

Consider colesevelam 3.8 g daily if the patient cannot tolerate bempedoic acid and triglycerides are <300 mg/dL. 2, 6

• Colesevelam reduces LDL-C by approximately 15-18% as monotherapy 6
• It provides a modest hypoglycemic effect beneficial in diabetic patients 2
• Avoid if triglycerides ≥300 mg/dL due to risk of further triglyceride elevation 2

Severe Hypertriglyceridemia Management:

If triglycerides >500 mg/dL, add fenofibrate to prevent acute pancreatitis. 2

If triglycerides 135-499 mg/dL in high-risk patients on optimized lipid therapy, consider icosapent ethyl 2 grams twice daily. 1, 2

Treatment Algorithm by Risk Category

Very High-Risk (Established ASCVD, recurrent events):

1. Ezetimibe 10 mg daily → Target LDL-C <55 mg/dL 1, 2
2. Add bempedoic acid 180 mg daily if LDL-C ≥55 mg/dL at 4-8 weeks 2
3. Add PCSK9 inhibitor if LDL-C remains ≥55 mg/dL (Class I recommendation) 1, 2

High-Risk (Diabetes with complications, multiple risk factors):

1. Ezetimibe 10 mg daily → Target LDL-C <70 mg/dL 1, 2
2. Add bempedoic acid 180 mg daily if LDL-C ≥70 mg/dL at 4-8 weeks 2
3. Consider PCSK9 inhibitor if LDL-C remains ≥100 mg/dL (Class IIa recommendation) 1, 2

Moderate-Risk (Primary prevention, 10-year ASCVD risk 7.5-20%):

1. Ezetimibe 10 mg daily → Target LDL-C <100 mg/dL 2
2. Add bempedoic acid 180 mg daily if LDL-C remains significantly elevated 2
3. PCSK9 inhibitors not recommended for primary prevention unless baseline LDL-C ≥190 mg/dL 2

Monitoring Recommendations

• Reassess lipid profile 4-8 weeks after initiating or adjusting therapy 2
• For patients on PCSK9 inhibitors, assess LDL-C response every 3-6 months 2
• Once at goal, perform annual lipid monitoring unless adherence concerns exist 2
• Monitor liver function tests when using bempedoic acid 1, 2

Common Pitfalls to Avoid

Do not skip ezetimibe and bempedoic acid to go directly to PCSK9 inhibitors unless the patient has very high risk with markedly elevated LDL-C, as PCSK9 inhibitors are significantly more expensive and the ACC/AHA guidelines specifically recommend trying ezetimibe first 1, 2

Do not use bile acid sequestrants if triglycerides ≥300 mg/dL, as they can worsen hypertriglyceridemia 2

Do not assume all patients labeled "statin intolerant" are truly intolerant without confirming they have tried at least 2 different statins at appropriate doses 2

Refer to a lipid specialist if the patient has severe hypertriglyceridemia (>500 mg/dL), familial hypercholesterolemia, or baseline LDL-C ≥190 mg/dL not due to secondary causes 2

Lifestyle Modifications (Essential for All Patients)

• Reduce saturated fat to <7% of total calories and cholesterol to <200 mg/day 2
• Daily physical activity for at least 30 minutes, 5-7 days per week 2
• Target BMI 18.5-24.9 kg/m² 2
• Smoking cessation and alcohol moderation 2