Is Deprescription of Ezetimibe Safe in Familial Hypercholesterolemia Patients Taking Evolocumab?

Shyann Hang,Julieta Lazarte,Robert A Hegele

doi:10.1016/j.cjco.2021.12.005

Shyann Hang, Julieta Lazarte + Show 1 more

Open Access

https://doi.org/10.1016/j.cjco.2021.12.005

Copy DOI

Journal: CJC Open	Publication Date: Dec 17, 2021
License type: cc-by

Affiliation: Western University

Abstract

We evaluated whether low-density lipoprotein cholesterol (LDL-C) levels in familial hypercholesterolemia patients on triple lipid-lowering therapy would remain below intensification threshold values after withdrawal of ezetimibe. We included 13 heterozygous familial hypercholesterolemia patients with vascular disease who were treated with statin + ezetimibe + evolocumab; ezetimibe was discontinued at the patients’ request. After 3 months, LDL-C levels increased from 0.96 ± 0.51 to 1.54 ± 1.07 mmol/L. In 12 of 13 patients, the LDL-C level remained below 1.8 mmol/L. No adverse cardiovascular events were observed. Deprescribing ezetimibe reduced pill burden but increased LDL-C level, although usually not above the treatment intensification threshold for high-risk patients.

Highlights

Familial hypercholesteremia (FH) is characterized by increased plasma low-density lipoprotein cholesterol (LDL-C) levels, which place untreated patients at high risk of early atherosclerotic cardiovascular disease (ASCVD).[1]
A similar approach to treatment intensification when LDL-C exceeds 1.8 mmol/L is seen in US Lipid Guidelines,[3] while European Society of Cardiology (ESC) guidelines recommend a target LDL-C value of 1.4 mmol/L for patients at high risk of ASCVD, including FH patients.[4]
Strict threshold and target LDL-C values were merely aspirational for FH patients, but this has changed with availability of inhibitors of proprotein convertase subtilisin/kexin type 9 (PCSK9)

Summary

Introduction

Familial hypercholesteremia (FH) is characterized by increased plasma low-density lipoprotein cholesterol (LDL-C) levels, which place untreated patients at high risk of early atherosclerotic cardiovascular disease (ASCVD).[1]. Journal Pre-proof intensification in high risk patients, such as those with FH.[2] A similar approach to treatment intensification when LDL-C exceeds 1.8 mmol/L is seen in US Lipid Guidelines,[3] while European Society of Cardiology (ESC) guidelines recommend a target LDL-C value of 1.4 mmol/L for patients at high risk of ASCVD, including FH patients.[4]. If the threshold LDL-C value of 1.8 mmol/L in high risk patients is exceeded, combination therapy is required and ezetimibe is usually added.[1] PCSK9 inhibitors are very helpful in controlling LDL-C in FH patients as they incrementally lower LDL-C levels by 50%-60% when added to existing therapies.[1,2] Often all three medications are needed to help high risk FH patients achieve desirable LDL-C thresholds based on treatment.[5]

Methods

Results

Conclusion