Treatment of cholesterol undergoing big changes

Get ready to have a detailed discussion with your healthcare provider about your cholesterol. Health professionals are rethinking how they view high cholesterol due to new treatment guidelines and a new cholesterol-lowering medication.

Earlier this year, a consortium of nine leading medical associations, including the American College of Cardiology, issued updated guidelines for the management of cholesterol and triglycerides. The document substantially alters recommendations for treatment, a change that could mean more Americans will begin taking cholesterol-lowering medications or will switch to more effective medications.

The new cholesterol guidelines “emphasize several things that previous guidelines didn’t have,” says Dr. Andrew J. Weinstein, a cardiologist with Ascension St. Vincent’s, located on 14th Street in Fernandina Beach. “Cardiovascular disease is something you address early in life — not waiting until you’re 40 or 50. That is emphasized in the guidelines.”

About 1 in 4 U.S. adults has high levels of so-called “bad” cholesterol, low-density lipoprotein (LDL). High cholesterol raises the risk of heart attack and stroke. Cholesterol buildup in the arteries is the leading cause of death worldwide, according to the American Heart Association.

The new recommendations on cholesterol include:

• For people at low risk of heart disease: Maintaining LDL levels below 100 mg/dL.
• For people at medium risk: Maintaining LDL levels below 70 mg/dL
• For people at high risk: Maintaining LDL levels below 55 mg/dL.
  
  

The previous guidelines, issued in 2018, called for risk assessment beginning at age 40. The new guidelines suggest risk assessment beginning at age 30. Previously, routine lipid blood tests were recommended starting at age 20. The new document calls for an initial screening at age 10 to assess genetic conditions that cause high cholesterol, and baseline lipid screening at age 19.

Moreover, every person should have a lipoprotein a, dubbed Lp(a), test at least once in adulthood, according to the guidelines. Higher levels are associated with a greater risk of heart attack and stroke.

The guidelines also call for broader use of another test: a coronary artery calcium scan. The quick CT scan measures calcified plaque in the heart. It can be used, Weinstein says, along with cholesterol tests and other information, to estimate your future risk of heart disease.

The guidelines “emphasize, for the first time, that we can now easily and non-invasively assess how much plaque someone has with a coronary artery calcium scan,” Weinstein says. “It’s probably the best screening test we have for coronary artery disease. It’s an inexpensive test.”

The test is typically not covered by insurance, but it costs as little as $100 out of pocket.

A new medication to bring down LDL

The updated recommendations come at a time when treatment for high cholesterol is more effective. In July, the Food and Drug Administration approved a pill that can lower cholesterol levels well beyond what can be achieved with statins. Studies show the drug, called Lipfendra (generic name, enlicitide), can bring down LDL levels to 60 mg/dL or lower.

Unlike statins, Lipfendra works by inhibiting a protein called PCSK9. While injectable PCSK9 medications are already available, Lipfendra is an oral medication. It is expected to be available in pharmacies soon, according to the manufacturer, Merck.

“They dramatically lower lipid levels. It’s a very important class of therapy,” Weinstein says of the PCSK9 medications. “But up until now the patient has had to give subcutaneous injections every two weeks. It’s not a convenient medication. The oral form is an important advance that will expand the pool willing to take that medication.”

The medication is only for people who need additional help lowering cholesterol levels to optimal levels, he says.

From lifestyle intervention to testing to medications, there are several ways for people to achieve optimal cholesterol goals, he adds.

“It’s always a patient-driven process,” he says. “Patients come in with different risk factors, ages and concerns. So, as always, you want to tailor the therapy to a given patient’s needs.”