Pharmacist education also helps prevent side effects and maximize outcomes for the asymptomatic disease.
Hypercholesterolemia, a type of hyperlipidemia, is increasing in prevalence in the United States.
According to the CDC, 94 million adults have a total cholesterol (TC) level greater than 200 mg/dL, which is considered hyperlipidemia.1
Although this disease is asymptomatic, it can dramatically increase the risk of developing atherosclerotic cardiovascular disease (ASCVD). Counseling patients about medications for hyperlipidemia can improve adherence to therapy, prevent adverse drug reactions, and maximize outcomes.
Many patients require pharmacologic therapy to improve hypercholesterolemia, taking into account patient comorbidities and other factors. Patients with TC values greater than 200 mg/dL with no history of ASCVD should receive primary prevention, and patients with a history of ASCVD should receive secondary prevention.
For primary prevention, treatment goals are determined by patient factors, such as: B. chronic kidney disease, a family history of premature ASCVD, metabolic syndrome, and others. These patient factors classify patients into low, borderline, intermediate, and high risk groups. Pharmacists may recommend non-pharmacological treatment to patients at low risk (<5% risk of ASCVD).2 Primary care physicians perform a risk assessment in patients at borderline risk (5% to 7.5% risk of ASCVD) to determine the need for drug therapy.2 Patients at higher risk should receive pharmacological therapy.
Guidelines generally classify patients requiring secondary prevention as either not very high risk or very high risk.3 Clinical signs of very high risk ASCVD lead to deviations in the patient’s medication. To be classified as very high risk, patients must have a history of multiple serious ASCVD events or 1 serious event and multiple high-risk conditions.3 Table 13 describes these states.
Non-pharmacological intervention is a backbone of prevention and treatment. In order to achieve the best treatment outcomes, it is crucial to educate patients on how to manage their lifestyle. Diet, exercise, and other lifestyle recommendations can lower cholesterol levels. Weight loss associated with lifestyle changes offers additional cholesterol benefits.4
As a first step, pharmacists may recommend tracking food intake. Eating heart-healthy meals reduces the risk of heart disease and stroke by controlling cholesterol levels. Fish and poultry are preferred to other meats.5 Fish has fewer saturated fats, and oily fish has omega-3 fatty acids that help reduce heart disease and stroke risk.5 Easy-to-implement recommendations for a heart-healthy diet include increasing fiber and whole grains and reducing dairy fats.
A sedentary lifestyle reduces levels of high-density lipoprotein (HDL), also known as good cholesterol.6 Even small amounts of daily exercise have been shown to reduce low-density lipoprotein (LDL) levels, also known as bad cholesterol, and improve HDL levels.7 Pharmacists may recommend as much physical exercise as possible, but different types of exercise offer different types of benefits. Regular exercise raises HDL cholesterol and displaces LDL. However, high-intensity aerobic exercise directly reduces LDL.7 Shared aerobic exercise like bicycling, brisk walking, and swimming can also improve blood sugar control, lung function, and weight loss.8th
Statins are the most commonly used medications to treat hypercholesterolemia. However, other less common drugs such as ezetimibe or PCSK9 inhibitors are available as add-on therapy or monotherapy.3
The dose of statin therapy is divided into 3 classifications: high, medium and low (cf Table 2).2 Statin intensity determines the lipid-lowering effect. Patients at higher risk for ASCVD use high intensity to lower lipids by more than 50%.3
Statin therapy is associated with muscle symptoms such as injury, myalgia, myopathy, and myositis. Healthcare providers should educate patients about possible side effects and how to report them to the doctor or pharmacist if they occur. However, recent studies have shown that these adverse effects (AEs) occur in less than 1% of patients.9
Another AEs of statin therapy is an increased risk of newly diagnosed diabetes mellitus. Most patients who develop diabetes while on statin therapy had pre-existing risk factors, but the rate of statin-induced diabetes is 0.2% of patients per year.9
In clinical practice, PCSK9 inhibitors, either alirocumab or evolocumab, are added to low-dose statin therapy or used as monotherapy in statin-intolerant patients.10 Compared to other monotherapies, PCSK9 inhibitors lowered lipid levels the most.10 In addition, they reduced the risk of cardiovascular events such as statin therapy.
When considering PCSK9 inhibitors, pharmacists must consider cost-effectiveness.
This therapy costs $14,350 per year, according to the Institute for Clinical and Economic Review.10
Despite being very effective, PCSK9 inhibitors will only become the first-line therapy once the price comes down.
AEs related to PCSK9 inhibitors are rare.11 Because PCSK9 inhibitors are injections, pharmacists should recommend administering the injection in the upper, outer upper arm, abdomen, or thigh of the patient.12
A less common drug, ezetimibe is an adjunct to statin drugs because PCSK9 inhibitors and statins are more effective.2.3 Common side effects include fever, headache, muscle aches, and sore throat.13
Involving patients in the decision-making process is important to achieve the best outcomes. table 3 lists easy-to-understand resources that pharmacists can recommend for patients with hypercholesterolemia.
About the author
Dylan Decandia is a PharmD candidate at the University of Connecticut School of Pharmacy at Storrs.
1. Facts about high cholesterol. CDC. July 12, 2022. Accessed July 14, 2022. https://www.cdc.gov/cholesterol/facts.htm
2. Grundy SM, Stone NJ, Bailey AL, et al. AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report from the American College of Cardiology/American Heart Association task force on guidelines for the clinical practice. Traffic. 2019;139(25):e1082-e1143. doi:10.1161/CIR.0000000000000625
3. Guideline 2018 on managing cholesterol in the blood. American College of Cardiology. Updated June 2019. Accessed 14 July 2022. https://www.acc.org/-/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Guidelines/2018/Guidelines-Made- Simple Tool 2018 Cholesterol.
4. Prevention and treatment of high cholesterol (hyperlipidemia). American Heart Association. Updated November 11, 2020. Accessed July 14, 2022. https://www.heart.org/en/health-topics/cholesterol/prevention-and-treatment-of-high-cholesterol-hyperlipidemia
5. Cooking to lower cholesterol. American Heart Association. Updated November 11, 2020. Accessed July 14, 2022. https://www.heart.org/en/health-topics/cholesterol/prevention-and-treatment-of-high-cholesterol-hyperlipidemia/cooking-to- lower- cholesterol
6. 11 foods that lower cholesterol. Harvard Health Publishing. August 13, 2021. Accessed July 14, 2022. https://www.health.harvard.edu/heart-health/11-foods-that-lower-cholesterol
7. Mann S, Beedie C, Jimenez A. Differential effects of aerobic exercise, resistance training, and combined exercise modalities on cholesterol and lipid profile: review, synthesis, and recommendations. sports medicine. 2014;44(2):211-221. doi:10.1007/s40279-013-0110-5
8. Aerobic exercise. Cleveland Clinic. Updated July 16, 2019. Accessed July 14, 2022. https://my.clevelandclinic.org/health/articles/7050-aerobic-exercise
9. Newman CB, Preiss D, Tobert JA, et al. Safety of statins and related
Adverse events: a scientific explanation from the American Heart Association. Arterioscler thrombus Vasc Biol. 2019;39(2):e38-e81. doi:10.1161/ATV.00000000000000073
10. Chaudhary R, Garg J, Shah N, Sumner A. PCSK9 inhibitors: a new era in lipid-lowering therapy. World J Cardio. 2017;9(2):76-91. doi:10.4330/wjc.v9.i2.76
11. Gürgöze MT, Müller-Hansma AHG, Schreuder MM, Galema-Boers AMH, Boersma E, Roeters van Lennep JE. Adverse events associated with PCSK9 inhibitors: a real-world experience. Clin Pharmacol Ther. 2019;105(2):496-504. doi:10.1002/cpt.1193
12. Lunven C, Paehler T, Poitiers F, et al. A randomized study of the relative pharmacokinetics, pharmacodynamics, and safety of alirocumab, a fully human anti-PCSK9 monoclonal antibody, following a single subcutaneous administration at three different injection sites in healthy volunteers. Cardiovascular Ther. 2014;32(6):297-301. doi:10.1111/1755-5922.12093
13. Brar KS. Ezetimibe (Zetia). Med J Armed Forces India. 2004;60(4):388-389. doi:10.1016/S0377-1237(04)80019-4