Experts have landed on 70 mg/dL as the threshold to consider adding a non-statin...AFTER verifying adherence to statins and lifestyle changes. The change is based on more data that "lower is better" in these patients.Continue to recommend a high-intensity statin (atorvastatin 80 mg, etc) for very high-risk patients. Then use a stepped approach if needed. Suggest adding ezetimibe first. It prevents one CV event for every 50 acute coronary syndrome patients treated for about 7 years...is well tolerated...and the generic costs about $360/yr. If LDL is still above 70 mg/dL, weigh pros and cons of injectable Praluent (alirocumab) or Repatha (evolocumab). Adding one of these PCSK9 inhibitors to a statin in patients with CV disease and other CV risks prevents about one CV event for every 70 patients treated for 2 to 3 yrs. But Repatha costs about $4,150/yr...Praluent about $13,400/yr. Payer contracts may result in similar costs for either med. Don't routinely suggest adding ezetimibe or a PCSK9 inhibitor for lower-risk CV disease patients. Help them stick to their statin instead.
Jan 29, 2019