The American College of Cardiology (ACC) has released guidance on the role of nonstatin therapies in the lowering of LDL cholesterol, as additional data on their use have become available since the ACC and American Heart Association (AHA) last updated the cholesterol guidelines in 2013. According to Donald M. Lloyd-Jones, MD, Northwestern University Clinical and Translational Sciences Institute, and Chair of the document’s writing committee, the goal of this latest guidance is to assist clinicians in interpreting the newest data for use in clinical practice and help guide their patients in making treatment decisions.
Seven different algorithms were produced for patients with cardiovascular disease or comorbidities and recommends the consideration of nonstatin drugs for patients at high risk whose LDL has not been reduced by 50% with lifestyle and statin therapy. The algorithms endorse the four evidence-based statin benefit groups already identified in the 2013 ACC/AHA cholesterol guidelines and assume the patient is taking a statin or has attempted statin therapy. Two different algorithms were created for patients with familial hypercholesterolemia (FH) and recommend a lower threshold for the use of PCSK9 inhibitors.
Although ezetimibe is considered appropriate for high-risk primary prevention, Dr. Lloyd-Jones said not enough data yet exists on PCSK9 inhibitors to support their use in primary prevention. PCSK9 inhibitor use, according to the document, should be reserved for those patients at highest risk (eg, those with FH, ACS, or those who are statin intolerant). Secondary prevention patients without FH should consider ezetimibe first. Bile acid sequestrants may be considered for those patients who cannot tolerate ezetimibe but should be avoided in those whose triglycerides exceed 300 mg/dL.
The next set of cholesterol guidelines will likely be published in the next few years after results from ongoing trials with PCSK9 inhibitors and the CETP inhibitor anacetrapib are completed.
For additional perspective from expert faculty, don’t miss the 11th Annual Cardiometabolic Health Congress this October 5-8, 2016 in Boston, MA. The breakfast symposium, “The New Face of Lipid Management for Patients with Hypercholesterolemia and Statin Intolerance” will take place on Thursday, October 6 and will be chaired by Dr. Steven E. Nissen. Later that day, Dr. Christie M. Ballantyne will chair a lunch symposium titled, “Patient-focused LDL-C Management and Risk Reduction in Clinical Practice: The Utility of PCSK9 Inhibitors.” See the complete agenda here.