The recent American College of Cardiology and American Heart Association cholesterol guidelines recommend initiating moderate or high-intensity statin monotherapy for patients with low-density lipoprotein (LDL) cholesterol levels of 4.91 mmol/L or greater to reduce their risk for atherosclerotic cardiovacualr disease (ASCVD), the leading cause of death for both men and women in the United States.
The challenge in clinical practice is that some patients do not respond to high-intensity statin monotherapy and adverse effects are common. Researchers reviewed published evidence to compare the clinical benefits, adherence, and harms of a lower-intensity statin combined with another lipid-modifying medication (bile acid sequestrant, ezetimibe, fibrate, niacin, or w-3 fatty acid) with those of higher-intensity statin monotherapy among adults at high risk for ASCVD. Combination therapy with bile acid sequestrants or ezetimibe decreased LDL cholesterol at least as well as higher-intensity monotherapy but data on adverse events was limited.
There was insufficient evidence regarding LDL cholesterol reduction when comparing moderated combination therapy with fibrates, niacin, or w-3 fatty acids. The researchers also found insufficient evidence to compare long-term clinical outcomes, such as mortality or acute coronary events. The full review will be published in Annals of Internal Medicine.