Statin Dosing for Familial Hypercholesterolemia

Initial Statin Selection and Dosing

The American Diabetes Association recommends high-intensity statin therapy, with atorvastatin 40-80 mg or rosuvastatin 20-40 mg, to achieve at least 50% LDL-C reduction from baseline in patients with familial hypercholesterolemia (FH) 1, 2
For adults with FH, the American College of Cardiology recommends starting with high-intensity statin therapy to achieve ≥50% LDL-C reduction from baseline 3

The European Society of Cardiology recommends target LDL-C goals based on risk level: <2.5 mmol/L (<100 mg/dL) for FH without ASCVD or other major risk factors, <1.8 mmol/L (<70 mg/dL) for FH with imaging evidence of ASCVD or other major risk factors, and <1.4 mmol/L (<55 mg/dL) for FH with clinical ASCVD 2
If LDL-C remains >100 mg/dL despite maximal tolerated statin therapy, the American Heart Association recommends considering adding ezetimibe 3

The American Academy of Pediatrics recommends not starting statin therapy before age 10 in boys and preferably after onset of menses in girls, and patients should ideally be at Tanner stage II or higher before initiating statin therapy 4, 5

The American College of Cardiology recommends measuring baseline CK, ALT, AST, glucose, and creatinine before starting statin therapy, and monitoring liver enzymes, muscle enzymes, and glucose as clinically indicated 2, 5

The European Society of Cardiology recommends considering combination of high-potency statin, ezetimibe, and PCSK9-targeted therapy as first-line treatment for extremely high-risk FH patients, and adding PCSK9 inhibitors if LDL-C goals are not achieved with maximally tolerated statin therapy and ezetimibe 2
The American Heart Association recommends adding ezetimibe to statin therapy for additional LDL-C reduction in FH patients 3