Be Prepared With Answers About the New Cholesterol Guidelines

You'll hear buzz about the new cholesterol guidelines that bring back some emphasis on LDL and promote even more individualization.

LDL will guide use of non-statins...but ONLY for the highest-risk patients with CV disease, such as those with multiple CV events OR additional CV risks (diabetes, smoking, etc).

Experts have landed on 70 mg/dL as the threshold to consider adding a non-statin...AFTER verifying adherence to statins and lifestyle changes. The change is based on more data that "lower is better" in these patients.

Continue to recommend a high-intensity statin (atorvastatin 80 mg, etc) for very high-risk patients. Then use a stepped approach if needed.

Suggest adding ezetimibe first. It prevents one CV event for every 50 acute coronary syndrome patients treated for about 7 well tolerated...and the generic costs about $360/yr.

If LDL is still above 70 mg/dL, weigh pros and cons of injectable Praluent (alirocumab) or Repatha (evolocumab). Adding one of these PCSK9 inhibitors to a statin in patients with CV disease and other CV risks prevents about one CV event for every 70 patients treated for 2 to 3 yrs.

But Repatha costs about $4,150/yr...Praluent about $13,400/yr. Payer contracts may result in similar costs for either med.

Don't routinely suggest adding ezetimibe or a PCSK9 inhibitor for lower-risk CV disease patients. Help them stick to their statin instead.

And don't suggest a bile acid sequestrant, fibrate, or niacin...these aren't shown to improve CV outcomes when added to a statin.

Individualization will be a bigger focus...for patients ages 40 to 75 who DON'T have CV disease. Use the Am Coll of Cardiology/Am Heart Assn CV risk estimator as a starting point to discuss if a statin is needed.

Advise using a high-intensity statin if 10-year CV risk is 20% or higher, since this level of risk is similar to having CV disease.

If CV risk is 7.5% to 19.9%, statin use will now be guided by "risk enhancers" history, kidney disease, etc. If patients have risks, generally suggest a moderate-intensity statin (atorvastatin 20 mg, etc).

Continue to recommend a statin for patients with diabetes ages 40 to 75. This improves outcomes...and is a Star Ratings quality measure.

Listen to PL Voices for insights from a guideline author. See our chart, 2018 ACC/AHA Cholesterol Guidelines, to get the full scoop.

Key References

  • J Am Coll Cardiol Published online Nov 8, 2018; doi:10.1016/j.jacc.2018.11.003
  • J Am Coll Cardiol Published online Nov 3, 2018; doi:10.1016/j.jacc.2018.11.004
  • J Am Coll Cardiol Published online Nov 3, 2018; doi:10.1016/j.jacc.2018.11.005
  • Medication pricing by Elsevier, accessed Dec 2018
Pharmacist's Letter. Jan 2019, No. 350101

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