Abstract
Purpose of ReviewFor many years, the lipid-lowering armamentarium consisted of statins and/or ezetimibe and/or bile acid sequestrants and/or fibrates. Now, with the availability of new drugs mostly injectables, the field has changed and the role of oral non-statin drugs (including bempedoic acid) must be reevaluated.Recent FindingsEzetimibe remains a very important combination partner for statins with continuously increasing treatment numbers. Bempedoic acid is another interesting combination partner for statin/ezetimibe or ezetimibe alone but lacks in contrast to ezetimibe evidence from outcome trials. The role of fibrates is less clear as they have shown disappointing results in outcome trials but may still be used in selected, high-risk patients with combined dyslipidemia. Bile acid sequestrants are now rarely used as there are stronger, better tolerable ways to lower LDL-cholesterol.SummaryWith the introduction of new injectable lipid-lowering drugs, some oral drugs such as ezetimibe and bempedoic acid still have an important spot in our treatment algorithm others such as fibrates have a less clear role while again others are now rarely used.
Highlights
The knowledge that lipids play an important role in atherogenesis and that lipid lowering translates into risk reduction for cardiovascular events has promoted the development of a number of new lipid-lowering drugs which can dramatically change the level of atherogenic lipoproteins. This is true for PCSK9 antibodies such as alirocumab and evolocumab or PCSK9 inhibitors based on siRNA technology such as inclisiran but is true for drugs used in rare conditions such as volanesorsen in familial chylomicronemia syndrome
The positioning of other oral lipid-lowering drugs (Table 1) often used in combination with statins may be less clear. It is questionable whether they can keep their present role considering that the newer injectable drugs mentioned above are usually used in combination with statins and show a convincing efficacy and safety profile
Bempedoic acid is an interesting new lipidlowering drug, which is primarily used in statin-intolerant subjects but may play a role in patients not reaching LDL-cholesterol target despite maximal statin end/or ezetimibe and/or PCSK9-based therapy (Table 2)
Summary
The knowledge that lipids play an important role in atherogenesis and that lipid lowering translates into risk reduction for cardiovascular events has promoted the development of a number of new lipid-lowering drugs which can dramatically change the level of atherogenic lipoproteins. This is true for PCSK9 antibodies such as alirocumab and evolocumab or PCSK9 inhibitors based on siRNA technology such as inclisiran but is true for drugs used in rare conditions such as volanesorsen in familial chylomicronemia syndrome. Outcome trials with statins Reduction of cardiovascular events (IMPROVEIT; SHARP) Not available No effect on cardiovascular events (ACCORD; FIELD) Not available
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