ACC Releases Guidance For Nonstatin LDL-C Reduction Therapy

The American College of Cardiology (ACC) has released an Expert Consensus Decision Pathway document for the lowering and management of low-density lipoprotein cholesterol (LDL-C) with nonstatin therapies.

The document follows the ACC’s 2013 cholesterol guidelines and comes in response to the several new trials investigating the use of 3 nonstatin medications for cholesterol lowering.
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At the time that the original guidance was released, no data were available on the safety and efficacy of nonstatin cholesterol-lowering therapy. For this reason, the guidance stated that nonstatin therapy should be considered only in patients who are either unable to take statins or have not seen adequate results with statin use.

“The goal was to provide practical guidance for clinicians and patients in situations not covered by the 2013 ACC/AHA guideline until such time as the next round of guidelines has the opportunity to formally review recent scientific evidence and cardiovascular outcomes trials are completed with new agents for [atherosclerotic cardiovascular disease] ASCVD risk reduction,” the report says.

Among the recommendations are:

  • In selected high-risk patients, nonstatins may be considered if maximally tolerated statin therapy has not achieved a reduction in LDL-C of greater than 50% from baseline.
  • Referral to a lipid specialist may be considered in higher-risk patients with statin intolerance.
  • Ezetimibe should be considered as a second-line therapy first in most patient scenarios.
  • Bile acid sequestrants may be considered as second-line therapy in patients who do not tolerate ezetimibe.
  • Alirocumab and evolocumab may be considered if the therapy goals have not been achieved on maximally tolerated statin and ezetimibe in higher-risk patients with clinical ASCVD or familial hypercholesterolemia.

“This expert consensus decision pathway addresses current gaps in care for LDL-C lowering to reduce ASCVD risk, and recommendations build on the evidence base established by the 2013 ACC/AHA cholesterol guideline,” the experts concluded.

“Recommendations attempt to provide practical guidance for clinicians and patients regarding the use of nonstatin therapies to further reduce ASCVD risk in situations not covered by the guideline until such time as the scientific evidence base expands and cardiovascular outcomes trials are completed with new agents for ASCVD risk reduction.”

—Michael Potts

Reference:

Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2016 ACC expert consensus decision pathway on the role of non-statin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2016;68(1):92-125.