John Smith is a 37-year-old Caucasian male who had an ischemic stroke 3 months ago. He was not taking any medications prior to the stroke. On the day of admission, his LDL-C was measured and found to be 140 mg/dL. At discharge, the patient received prescriptions for rosuvastatin 40 mg and aspirin 81 mg.
During his office visit today, his LDL-C is 84 mig/dL. His total cholesterol is 154 mg/dL, HDL-C is 42 mg/dL, triglycerides are 140 mg/dL.
The patient states he has been adherent to maximal lifestyle modifications and pharmacotherapy.
According to the 2017 Expert Consensus Decision Pathway (ECDP) on non-statin therapies for LDL-C lowering in the management of atherosclerotic cardiovascular disease risk, which ONE of the following choices is the best consideration at this time?
Show Answer
The correct answer is: D. Continue rosuvastatin 40 mg. Add ezetimibe 10 mg PO daily.
The patient has clinical ASCVD and is taking a high-intensity statin for secondary prevention. The patient states he is taking the high intensity statin therapy and following maximum lifestyle modifications.
The 2017 focused update to the ACC ECDP on non-statin therapies for LDL-C lowering in the management of ASCVD included thresholds to guide decision making when considering the addition of non-statin medications. For a patient with clinical ASCVD, the thresholds for considering the addition of non-statin therapy are when the patient achieves <50% LDL-C reduction from baseline, the LDL-C is >70 mg/dL, or if the non-HDL-C is >100 mg/dL on maximally tolerated statin therapy. Mr. Smith achieved a 40% LDL-C reduction from baseline, his current LDL-C is 84 mg/dL, and his non-HDL-C is 112 mg/dL.
The clinician and patient should discuss potential additional ASCVD risk reduction from additional LDL-C lowering, risk of adverse effects, potential drug-drug interactions, and patient preferences before a non-statin is prescribed. Using the 2017 ACC ECDP algorithm, either ezetimibe or a PCSK9 inhibitor may be considered as add-on therapy to this patient's rosuvastatin 40 mg for additional LDL reduction.
Ezetimibe may be favored as the initial add-on choice for patients who require <25% LDL-C reduction. This patient needs ~17% LDL-C reduction to achieve the LDL-C threshold <70 mg/dL, so ezetimibe (Option D) would be the favored initial choice agent.
Option C is not the best choice for the patient at this time. According to the 2017 ECDP for non-statins, a PCSK9 inhibitor may be favored as the initial add-on choice if >25% LDL-C reduction is needed. This patient needs ~17% LDL=C reduction to achieve the LDL-C threshold <70 mg/dL.
Options A and B are not the best options for this patient. In option A, both medication regimens are high-intensity statin therapy. Option B includes a moderate-intensity statin with ezetimibe. The 2013 ACC/AHA cholesterol guideline recommends the use of a high-intensity statin therapy for patients diagnosed with clinical ASCVD, and the 2017 ECDP for non-statins recommends the use of a maximally tolerated statin therapy before a non-statin therapy should be considered.
References
Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2017 focused update of the 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 Expert Consensus Decision Pathways. J Am Coll Cardiol 2017;70:1785-1822.
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2889-934.
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