From the Guidelines
Treatment for high LDL cholesterol (4.0 mmol/L or approximately 155 mg/dL) typically involves both lifestyle modifications and possibly medication, with the primary goal of reducing cardiovascular risk. To manage high LDL cholesterol, start with dietary changes including reducing saturated and trans fats, increasing fiber intake, and consuming more plant sterols found in vegetables, fruits, and whole grains 1. Regular physical activity of at least 150 minutes per week of moderate-intensity exercise is recommended. Weight loss if overweight can significantly improve cholesterol levels. For medication, statins are the first-line treatment, with options including atorvastatin (10-80 mg daily), rosuvastatin (5-40 mg daily), or simvastatin (10-40 mg daily) 1. If statins aren't tolerated, ezetimibe (10 mg daily) or PCSK9 inhibitors may be considered. Some key points to consider:
- Therapeutic lifestyle changes (TLC) remain an essential modality in clinical management, with the potential to reduce cardiovascular risk through several mechanisms beyond LDL lowering 1.
- In high-risk persons, the recommended LDL-C goal is <100 mg/dL, with a therapeutic option of <70 mg/dL for those at very high risk 1.
- For moderately high-risk persons, the recommended LDL-C goal is <130 mg/dL, with a therapeutic option of <100 mg/dL based on available clinical trial evidence 1.
- Any person at high risk or moderately high risk who has lifestyle-related risk factors is a candidate for TLC to modify these risk factors regardless of LDL-C level 1.
- When LDL-lowering drug therapy is employed, it is advised that intensity of therapy be sufficient to achieve at least a 30% to 40% reduction in LDL-C levels 1. The most recent and highest quality study 1 supports the use of statins as the first-line treatment for high LDL cholesterol, with lifestyle modifications as an essential component of therapy.
From the FDA Drug Label
EZETIMIBE Tablets is indicated (1): • In combination with a statin, or alone when additional low density lipoprotein cholesterol (LDL-C) lowering therapy is not possible, as an adjunct to diet to reduce elevated LDL-C in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH)
Atorvastatin calcium is indicated as an adjunct to diet to reduce elevated total-C, LDL-C, apo B, and TG levels and to increase HDL-C in patients with primary hypercholesterolemia (heterozygous familial and nonfamilial) and mixed hyperlipidemia
Treatment for high LDL: 4.0
- Ezetimibe can be used in combination with a statin, or alone when additional low density lipoprotein cholesterol (LDL-C) lowering therapy is not possible, as an adjunct to diet to reduce elevated LDL-C in adults with primary hyperlipidemia.
- Atorvastatin can be used as an adjunct to diet to reduce elevated total-C, LDL-C, apo B, and TG levels and to increase HDL-C in patients with primary hypercholesterolemia. The choice of treatment depends on the individual patient's condition and medical history. It is recommended to consult with a healthcare professional to determine the best course of treatment. 2 3
From the Research
Treatment Options for High LDL Cholesterol
- Statins are the first-line therapy for reducing LDL cholesterol levels and preventing atherosclerotic cardiovascular disease (ASCVD) 4
- For patients who require additional LDL cholesterol reduction, ezetimibe, a cholesterol absorption inhibitor, can be added to statin therapy to further reduce LDL cholesterol levels and decrease ASCVD risk 4, 5
- PCSK9 inhibitors, such as alirocumab and evolocumab, can also be used to lower LDL cholesterol levels in patients who require more intensive therapy 4
Efficacy of Ezetimibe in Combination with Statins
- Studies have shown that the combination of ezetimibe and simvastatin can significantly reduce LDL cholesterol levels and improve cardiovascular outcomes compared to simvastatin monotherapy 5, 6
- Ezetimibe/simvastatin combination therapy has been shown to be more effective in reducing LDL cholesterol levels than rosuvastatin or atorvastatin in certain patient populations 6, 7
Real-World Outcomes and Treatment Goals
- Despite the availability of effective treatments, many patients with ASCVD do not achieve their target LDL cholesterol goals, highlighting the need for more intensive lipid-lowering therapy 8
- The use of high-intensity or very high-intensity lipid-lowering therapies can help reduce the risk of recurrent ASCVD events, but more work is needed to improve treatment outcomes and achieve target LDL cholesterol levels 8