Cholesterol management

risk factors: cigarette smoking, HTN, low HDL, family history of premature coronary heart
disease, diabetes, chronic kidney disease (CKD)

 High risk patients

o those with atherosclerotic CVD or non-coronary forms of atherosclerotic disease
(eg., peripheral arterial disease, aortic aneurysm, carotid artery disease,
transient ischemic attacks), LDL > 190
 high-intensity statin if <75 YO & no contraindications
 moderate-intensity statin if >75 YO

o patients b/t 40-75 with type 1 or 2 diabetes & LDL b/t 70-189  estimate 10-
year atherosclerotic CVD risk
 if risk < 7.5%  moderate-intensity statin
 if risk > 7.5%  high-intensity statin

 low risk patients

o less intensive treatment
o pharmacologic therapy is usually indicated if lifestyle changes are ineffective in
the short term (3 to 6 months).

 patients usually treated with statins unless contraindicated in addition to lifestyle

modifications
o A/E: elevated liver enzymes, myositis & rhabdomyolysis

 patients that are intolerant to statins or those that need additional LDL-cholesterol
lowering after maximum tolerated statin therapy 
o ezetimibe (blocks cholesterol absorption)
o fibrates
o niacin & bile acid sequesterants

 Other therapies
o Niacin
 useful in reducing LDL-cholesterol and triglycerides
 A/E: flushing in 80% of patients; nausea in 20% of patients (Pretreatment
with aspirin 325 mg, 30 minutes prior to dosing, can minimize flushing
and other prostaglandin-mediated adverse effects)
o Bile acid sequesterants
 bind to bile acids & prevent absorption
 A/E: nausea, bloating, cramping, and increased hepatic transaminases
o Ezetimibe
 impairs dietary and biliary cholesterol absorption at the intestinal brush
border
o PCSK9 monoclonal antibodies
 PCSK9 normally binds to LDL receptors, facilitating their degradation
 When in excess, PCSK9 is a cause of familial hypercholesterolemia
 therefore, PCSK9 inhibitors are associated with lower LDL-cholesterol
levels and a reduced risk of cardiovascular events
 when to use?
 patients with familial hypercholesterolemia
 patients with clinical atherosclerotic cardiovascular disease, such
as heart attacks or strokes, who require additional lowering of
LDL-cholesterol.
o Fibrates
 may be added to statins, but only in the presence of mixed dyslipidemia
when reductions in both cholesterol and triglycerides are necessary. This
association must be done with care because it increases the risk of
rhabdomyolysis. Gemfibrozil is never to be used in association with a
statin. Fenofibrate and fenofibric acid are the drugs of choice for the
association with a statin