When to initiate antidyslipidemic (anti-dyslipidemia) medications for a patient with hypercholesterolemia who is otherwise medically free?

From the Guidelines

Medication for high cholesterol should be considered in individuals without other medical conditions when their 10-year risk of cardiovascular disease exceeds 7.5% or when they have an LDL-C level of 1.8 mmol/L (70 mg/dL) or higher, particularly in those aged 40 to 75 years, as recommended by the 2018 American Heart Association/American College of Cardiology/Multisociety Cholesterol Guideline 1. When deciding to start anti-dyslipidemia medications, several factors must be considered, including the patient's overall cardiovascular risk, LDL-C levels, and the presence of diabetes mellitus.

• For adults aged 40 to 75 years with diabetes mellitus and an LDL-C level of 1.8 mmol/L (70 mg/dL) or higher, starting moderate-intensity statin therapy is recommended without the need to calculate 10-year ASCVD risk 1.
• In adults aged 40 to 75 years without diabetes mellitus who have LDL-C levels of at least 1.8 mmol/L (70 mg/dL) and a 10-year ASCVD risk of 7.5% or higher, moderate-intensity statin therapy is recommended if a discussion of treatment options favors statins 1.
• For those with severe primary hypercholesterolemia, often starting in childhood, maximally tolerated statin therapy is required to reduce LDL-C levels toward a lower risk range, with the consideration of adding ezetimibe or a PCSK9 inhibitor if necessary 1. The goal of treatment is to reduce the risk of cardiovascular disease by lowering LDL cholesterol levels, and statins are the first-line medication choice due to their efficacy and safety profile, as supported by the 2018 guidelines 1. Regular monitoring of lipid levels and liver function tests is crucial, and potential side effects such as muscle pain, liver enzyme elevations, and a slightly increased risk of diabetes should be discussed with patients before initiating therapy. In the context of real-life clinical medicine, prioritizing the reduction of morbidity, mortality, and improvement of quality of life, starting anti-dyslipidemia medications in accordance with the latest guidelines is essential for managing high cholesterol effectively.

From the FDA Drug Label

To reduce the risk of major adverse cardiovascular (CV) events (CV death, nonfatal myocardial infarction, nonfatal stroke, or an arterial revascularization procedure) in adults without established coronary heart disease who are at increased risk of CV disease based on age, high-sensitivity C-reactive protein (hsCRP) ≥2 mg/L, and at least one additional CV risk factor. As an adjunct to diet to: Reduce low-density lipoprotein cholesterol (LDL-C) in adults with primary hyperlipidemia.

The decision to start anti-dyslipidemia medications for someone who is medically free but has high cholesterol should be based on their individual risk factors for cardiovascular disease.

• Key factors to consider include age, high-sensitivity C-reactive protein (hsCRP) levels, and the presence of additional cardiovascular risk factors.
• Initiation of therapy may be considered in adults without established coronary heart disease who are at increased risk of CV disease.
• The recommended dosage of rosuvastatin tablets depends on a patient’s indication for usage, LDL-C, and individual risk for CV events, with a dosage range of 5 mg to 40 mg orally once daily 2.
• For atorvastatin, the recommended starting dosage is 10 or 20 mg once daily, with a dosage range of 10 mg to 80 mg once daily 3.

From the Research

Determining the Start of Anti-Dyslipidemia Medications

When considering the initiation of anti-dyslipidemia medications for an individual who is medically free but has high cholesterol, several factors come into play. The decision is largely based on the patient's vascular risk and their low-density lipoprotein cholesterol (LDL-C) levels.

Vascular Risk and LDL-C Levels

• Vascular diseases are a leading cause of death, and hypercholesterolemia is a significant risk factor for cardiovascular disease 4.
• Reducing LDL-C levels is essential to decrease the risk of vascular complications, and the goal is to achieve the levels recommended by clinical practice guidelines 4.
• The choice of lipid-lowering therapy should be adjusted to the patient's needs based on their LDL-C levels and vascular risk 4.

Treatment Options

• Rosuvastatin, alone or in combination with ezetimibe, is effective in providing intensive LDL-C reductions with a low risk of side effects 4, 5.
• The combination of rosuvastatin and ezetimibe has been shown to be safe and effective in patients with hypercholesterolemia or dyslipidemia, enabling higher proportions of patients to achieve recommended LDL-C goals 5.
• Comparisons between rosuvastatin and atorvastatin have indicated that rosuvastatin can be more efficacious in reducing LDL-C levels and enabling LDL-C goal achievement in high-risk patients with hypercholesterolemia 6, 7, 8.

Considerations for Starting Medication

• The decision to start anti-dyslipidemia medication should be based on the patient's overall risk profile and LDL-C levels, rather than solely on the presence of high cholesterol 4.
• Current guidelines recommend initiating lipid-lowering therapy in patients with high or very high vascular risk, even if their LDL-C levels are not severely elevated 4.
• The choice of medication and the timing of initiation should be individualized, taking into account the patient's specific needs and risk factors 5.