Medications for Lipid Control: Statins vs Newer Drugs.

Abstract

In the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD), statins are the primary pharmacologic intervention for ASCVD risk reduction. Statins have proven efficacy and safety in reducing cardiovascular events and total mortality in patients with and without clinically evident ASCVD. The purpose of this brief review is to provide a stepwise approach to lipid management, including lifestyle recommendations and medical therapy. We first review the main available approaches to lipid lowering and their mechanisms of action. We then summarise the findings of large randomised controlled trials investigating the benefit of statin therapy from 1994 to the present. The available statins are then reviewed, along with their main pharmacologic properties and potential adverse effects. Although statins are generally well tolerated, certain patients may require dose adjustments or alternative treatments because of side-effects. In patients not achieving adequate lipid control on a maximally tolerated statin, nonstatin medications, including ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, provide enhanced low-density lipoprotein cholesterol reduction and cardiovascular benefits, especially in high-risk patients inadequately managed with statins alone. We review the role of triglyceride-lowering agents, including fibric acid derivatives and icosapent ethyl. We then deal with special populations, including those with hepatic steatosis, chronic kidney disease, pregnancy, and heart failure. This field continues to progress, and novel therapies are under active investigation, including an oral PCSK9 inhibitor and molecular therapies targeting lipoprotein(a), angiopoietin-like protein 3, and apolipoprotein CIII. We can look forward to exciting developments that will have major impacts on patient health and management.