New Developments in Cholesterol Treatment

By Joyce Oen-Hsiao, as told to Keri Wiginton

Right now, cholesterol treatment is more about finding ways to combine current cholesterol drugs a little bit differently and target treatment based on the person themselves. It’s not just standardized — giving everyone a statin right away. New research is about targeting which therapies are better for the elderly, which therapies are better for people with cancer, things like that.

There’s a new drug called Nexletol, and it’s used for people with the highest risk. That’s people with genetic or familial high cholesterol or those who have heart disease and further need to lower their cholesterol. It’s called bempedoic acid. It works to lower the cholesterol your liver makes.

Statins are different because they lower cholesterol in the blood by reducing the liver’s ability to make cholesterol. This then allows the liver to accept more cholesterol from the blood, thereby driving down cholesterol levels. They can drive down low-density lipoprotein (LDL) through the HMG receptor. This is an enzyme that processes cholesterol in the body. But Nexletol actually holds up cholesterol production in the liver as well, but through a different enzyme on a pathway known as the ACL pathway.

Other drugs that have come over the last couple of years are the PCSK9 inhibitors. These are great because they act to lower the cholesterol in a totally different way than a statin. They don’t give the muscle aches. And they don’t necessarily give the liver toxicity, as well.

The only issue with a PCSK9 inhibitor is that it’s an injection. Luckily, you only have to give yourself a shot every 2 weeks, so it’s really not that often. We’ve been using it a lot more in people who have trouble getting their LDL controlled.

It’s also very good for people with familial hypercholesterolemia. This is an inherited disorder in which the body doesn’t recycle LDL cholesterol correctly, so your blood levels are always high unless you get treatment. FH happens when there is a mutation to one of several genes in the body. Most often it is in the LDL-receptor gene that helps to find and remove cholesterol in the body.

Nexletol is also a good starting point before you start doing LDL apheresis — when doctors filter your blood to remove LDL cholesterol.

Another newer option is actually a statin. It’s called pitavastatin, or Livalo. It has the same LDL- and total cholesterol-lowering property as all the other statins, but somehow doesn’t give the muscle aches. A lot of people have had a lot of success taking this over any of the other statins out there. It gets their LDL down to where it needs to be.

Most of the time, if people get onto a good lifestyle modification of diet and exercise, they can usually drop their bad cholesterol maybe about 20-30 points. They can often drop their statin to the lowest dose, if they continue following those good lifestyle choices.

And I’ve seen a handful of people who’ve been able to come completely off cholesterol medications. 

More often than not, I ask people to make lifestyle changes, and they say, “Doc, you know I’m not going to exercise.” Then we talk about their risk factors. I say, “OK, if you’re not going to change your lifestyle, then at this point we have to give you medication to lower your cardiovascular risk of stroke and myocardial infarction and other health problems.” If you do it right, you can have this open dialogue with people to figure out what is the best option for them.