Features May 2015 Issue

Is Your Statin Not Getting Your LDL Levels to Your Target?

Research suggests you may have more blocked arteries than previously thought. But a new medication poised for approval could provide some help.

Images: Thinstock

You take a statin as prescribed by your doctor, but your low-density lipoprotein (LDL or “bad”) cholesterol levels aren’t dropping as expected. If that’s been your experience, it could indicate that you simply need a stronger dose of statins.

Then again, it may be that you’re one of the estimated 20 percent of people with heart disease who don’t respond to the cholesterol-lowering drugs. And as a recent study found, statin resistance could indicate significant blockage in your arteries.

The research, published in Arteriosclerosis, Thrombosis, and Vascular Biology, further supports the idea that aggressive cholesterol control is vital to protecting heart patients. Other studies have found that statins not only lower the risk of cholesterol plaque buildup in the arteries, but they slow the progress of atherosclerosis.

“If you don’t get your LDL cholesterol to the goals you need, your heart disease will progress more, and you will be more likely to have a cardiovascular event,” says Steven Nissen, MD, chairman of Cardiovascular Medicine at Cleveland Clinic and one of the physicians involved with the study. He adds that your LDL goal may differ from someone else’s target because of other health factors. “The higher the risk the patient is, the lower we want to get that number,” he says.

Exploring options

While improving LDL levels with a stronger dose of statins may be an easy solution, Dr. Nissen says there are certain steps that should be taken before changing medications or intensifying the therapy.

“The first thing we do before increasing the dose is to make sure they’re taking their medications properly,” he says. “Usually they are. For some patients, the answer is prescribing a second drug—not an additional statin, but a cholesterol absorption inhibitor.”

A commonly prescribed cholesterol absorption inhibitor is ezetimibe (Zetia®). It is widely prescribed by many doctors as a second-line therapy for patients intolerant of statins or who are unable to reach their LDL goals. A 2014 study found that the combination of ezetimibe and simvastatin not only lowered LDL levels, but it also reduced the risk of heart attacks and strokes. For some patients, changing the type of statin is enough to get the desired results. But Dr. Nissen also notes that patients can help themselves by exercing regularly and eating a balanced diet.

A new option emerges

A second non-statin medication that may help statin-intolerant patients also appears poised to hit the market in the months ahead. PCSK9 inhibitors evolocumab (Repatha®) and alirocumab (Praluent®) cut the risk of heart attack and stroke by about 50 percent in a study presented at the 2015 American College of Cardiology conference.

“PCSK9 inhibitors will be just terrific for people who need to get their LDL down,” Dr. Nissen says.

He says he expects the U.S. Food and Drug Administration to approve the medications this summer. How quickly they become standard in clinical care will depend on several factors, such as price and how insurance companies deal with the new medications.

“I expect we’ll see limited approval for the highest-risk patients at first,” Dr. Nissen says.

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