Beyond Statins: Who and When to Prescribe?

Statins, gut microbiome, LDL-C, glucose intolerance: Personalized medicine timely?

Statins are a mainstay in reducing cardiovascular disease risk by reducing circulating levels of plasma LDL-C. In this issue of Med, Wilmanski et al. demonstrate how the composition of the gut microbiome influences the pharmacological benefits and risks of statin therapy, an exciting additional step in personalized medicine.

Statins Versus Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors- Are We Doing Better? A Systematic Review on Treatment Disparity

Coronary artery disease (CAD) is a significant contributor to mortality in America. A common risk factor of CAD is hyperlipidemia. Treatment guidelines of hyperlipidemia are well established. Statins are the cornerstone of treating hyperlipidemia. New medications such as proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9 inhibitors) have also illustrated significant results in treating hyperlipidemia. While multiple studies exemplify the disparities in statin and PCSK9 inhibitors utilization to reduce CAD mortality and risk factors, there are no systematic reviews to validate these disparities. We conducted a search on PubMed, including Medline and PubMed Central, and Google Scholar. For this analysis, we selected articles published between 2000 and 2020 and those that fit the inclusion and exclusion criteria. Based on the type of study, we performed appropriate quality assessments and deleted studies with a score of less than seven or with a high risk of biases. The search strategy resulted in 322 studies. After inclusion and exclusion criteria were applied, we included 20 articles in the analysis of this review. This systematic review demonstrates that non-white races and women were less likely to receive the correct, clinically indicated, therapy for hyperlipidemia. A multi-faceted approach is required to solve this inequality in healthcare.

When to lower triglycerides?

PURPOSE OF REVIEW

Substantial risk of ASCVD events persists despite intensive statin therapy and other agents to lower LDL-C. The optimal way to address other elements of dyslipidemia, such as triglyceride-rich particles (TRL) and when to treat has remained unclear.

RECENT FINDINGS

Several lines of evidence indicate that TRL are associated with atherogenesis, partly because of associated factors, such as cholesterol-enriched remnant particles, high LDL particle number, high apo-B, high apo-CIII, and others. High triglyceride is increasingly prevalent because of worsening of lifestyle factors, obesity, and diabetes. Trials with fibrates, and niacin to reduce residual dyslipidemia have not provided evidence of benefits after statin therapy, thus far. A recent trial with an omega 3 fatty acid (OM3FA), icosapent-ethyl (IPE), provided evidence for a 25% reduction in ASCVD events in statin-treated high-risk population. These results were unexplained by triglyceride reduction alone, and are likely related to unique biologic effects of IPE on atherosclerosis. Finally, in patients with very high triglycerides, lifestyle measures and several triglyceride-lowering agents are indicated, often in combination, to prevent episodes of pancreatitis. A novel Apo C-III inhibitor may provide additional benefit in such patients.

SUMMARY

There is evidence for the benefits of IPE in preventing ASCVD events. A novel fibrate is in clinical trials.