High LDL cholesterol can increase the risk of cardiovascular disease by contributing to plaque build-up within the arteries. Statins are commonly used as first-line treatment because they can lower LDL cholesterol and reduce cardiovascular risk.
However, some people may not reach their recommended LDL target with statins alone, while others may have difficulty tolerating an adequate dose. In these situations, treatment may need to be reviewed and additional options considered.
Why Might Statins Not Be Enough?
Statins are effective at reducing LDL cholesterol, but some people may require additional treatment to achieve an appropriate LDL level.
This is particularly relevant for individuals with established cardiovascular disease, familial hypercholesterolaemia or a higher overall risk of heart attack or stroke.
Treatment goals are determined according to individual cardiovascular risk, existing medical conditions and response to treatment.
What Other Treatment Options May Be Considered?
When LDL cholesterol remains above the recommended target despite the maximum tolerated statin dose, additional cholesterol-lowering medications may be considered.
Ezetimibe: An oral medication that reduces cholesterol absorption in the intestine. It is commonly used alongside statins when further LDL reduction is required.
PCSK9 inhibitors: Injectable treatments, such as evolocumab and alirocumab, that can substantially reduce LDL cholesterol. They may be considered for selected high-risk patients, including those with established cardiovascular disease or familial hypercholesterolaemia.
Bempedoic acid: An oral non-statin medication that lowers LDL cholesterol and may be considered for selected patients, particularly where statin intolerance is a concern. Availability and prescribing arrangements in Australia should be confirmed.
The most suitable option depends on the patient’s cardiovascular risk, LDL levels, previous treatment response and individual circumstances.
What If Statins Are Difficult to Tolerate?
Some people experience symptoms, including muscle discomfort, while taking statins. However, these symptoms are not always caused by the medication.
A clinical review may consider the timing of symptoms, current dosage, possible medication interactions and other contributing factors.
Depending on the findings, management may involve adjusting the dose, trying another statin or considering additional cholesterol-lowering therapy.
Patients should discuss any changes with their treating clinician rather than stopping prescribed treatment independently.
How Is the Right Approach Decided?
Cholesterol management requires an individual assessment of LDL levels, overall cardiovascular risk, medical and family history, and response to previous treatment.
For some patients, adjusting existing statin therapy may be sufficient. Others may benefit from adding a non-statin medication to achieve further LDL reduction.
The goal is not simply to lower a cholesterol number but to reduce the long-term risk of cardiovascular events through an appropriate, evidence-based treatment plan.
How Treatment Decisions Are Made?
Statins remain an important first-line treatment for high LDL cholesterol, but they may not achieve the required reduction for every person. When LDL remains above target or an adequate statin dose cannot be tolerated, additional treatment options may be considered as part of an individual cardiovascular risk management plan.
Lifestyle measures remain an important part of cardiovascular risk management, even when medication is required. A heart-healthy eating pattern, regular physical activity, not smoking and management of conditions such as diabetes and high blood pressure all contribute to cardiovascular health.These measures support, rather than replace, prescribed cholesterol-lowering treatment.