Management of Mixed Hyperlipidemia in Statin-Declining Patients

Patient Profile and Risk Assessment

A 65-year-old male with mixed hyperlipidemia and established coronary artery disease has an LDL-C of 121 mg/dL, elevated apolipoprotein B, and a cholesterol-HDL ratio of 5.0, with a family history of ischemic heart disease and essential hypertension 1

The American College of Cardiology recommends that nonstatin therapies are not considered alternatives to evidence-based statin therapy unless statin-associated side effects have been systematically and rigorously evaluated and documented 1

The American College of Cardiology suggests that statin-rechallenge and education should be the first attempt, including counseling that statins remain first-line therapy for hyperlipidemia with established ASCVD 1, 2
Consider trial of alternative statins with different metabolic pathways, such as hydrophilic statins like rosuvastatin or pravastatin 1
If statin rechallenge fails, alternative statin dosing strategies, including alternate-day dosing with long half-life statins or de-escalation dosing, may be considered 1
Ezetimibe should be considered first-line non-statin therapy for statin-intolerant patients, with bempedoic acid as an alternative due to lower rates of muscle-related adverse effects 2
PCSK9 inhibitors, including inclisiran, should only be considered after documented statin intolerance 1, 3

Attempt statin rechallenge with a different statin at the lowest approved dose 1
If statin intolerance is confirmed, consider ezetimibe as first-line non-statin therapy 2
Only consider inclisiran after documented statin intolerance and failure of first-line non-statin therapies 1, 3
Continue lifestyle modifications, including exercise, improved diet, and reduced processed foods 2