Lowering her LDL, the options in order
In order, with the evidence under each
A different statin from the simvastatin she stopped, at a moderate dose. Her aches of 2024 fit statin-associated muscle symptoms with a CK below four times the upper limit, the pattern in which the consensus advises a second attempt.
CTT meta-analysis, 27 randomised trials, 174,149 participantsversus placebo or a less intensive statin
- Major vascular events per 1 mmol/l of LDL
- RR 0.79 (0.77–0.81)
- Muscle pain or weakness, statin versus placebo
- 27.1 % versus 26.6 %
- Population studied
- Adults with and without vascular disease. The analysis reports people with a five-year risk below 10 % separately.
- Where she differs
- The trials did not select people with earlier muscle symptoms. For that question, the blinded trials stand in the evidence answer.
- Data maturity
- Individual participant data with about five years of follow-up. The pooled analysis of muscle symptoms followed in 2022.
- Guideline
- ESC/EAS 2019: at moderate risk an LDL goal below 100 mg/dl, with a statin as the first step. EAS consensus 2015: after muscle symptoms, a rechallenge with a different statin. ESC/EAS 2019
If the aches come back, check the CK and pause the tablet. Do not raise the dose into the symptoms.
The second statin if atorvastatin brings the aches back. It lowers LDL at a small dose, which keeps the dose low for a patient who has reacted once.
JUPITER, 17,802 randomised, rosuvastatin 20 mgversus placebo
- Primary endpoint, hazard ratio (95 % CI)
- 0.56 (0.46–0.69)
- LDL reduction
- 50 %
- Population studied
- Men and women without cardiovascular disease, with an LDL below 130 mg/dl and an hsCRP of 2 mg/l or more.
- Where she differs
- Her LDL is higher than the trial allowed, and the dose studied was four times the one proposed here.
- Data maturity
- Stopped early after a median of 1.9 years for benefit, which tends to overstate the size of an effect.
- Guideline
- ESC/EAS 2019: statins as the first step; the choice of statin and dose follows tolerance and the distance to the goal. ESC/EAS 2019
- Sources
- Ridker, NEJM 2008
Neither is a statin. Ezetimibe lowers the uptake of cholesterol from the gut. Bempedoic acid acts one step before the statins and is activated only in the liver, which is why it was studied in people who could not take a statin.
CLEAR Outcomes, 13,970 randomised, bempedoic acid 180 mgversus placebo
- Major cardiovascular events, hazard ratio (95 % CI)
- 0.87 (0.79–0.96)
- LDL reduction beyond placebo
- 21.1 percentage points
- Gout
- 3.1 % versus 2.1 %
- Gallstones
- 2.2 % versus 1.2 %
- Population studied
- People who could not take a statin, with cardiovascular disease or at high risk of it. About 30 % were in primary prevention.
- Where she differs
- Her risk is lower than that of the trial population, so the absolute benefit for her would be smaller.
- Data maturity
- Event-driven, median follow-up 40.6 months.
- Guideline
- ESC/EAS 2019: ezetimibe if the goal is not reached on the tolerated statin dose, or alone if no statin is tolerated. ESC/EAS 2019
- Sources
- Nissen, NEJM 2023
Bempedoic acid raises uric acid. One value before the start is worth it in anyone with gout in the history.
Checked against everything she takes
Her medication list of 16 September, read against the product information of the option ranked first.
Read from her own record, not from the guideline
- Simvastatin 20 mg, March 2024: muscle aches in both thighs, CK 210 U/lBelow four times the upper limit and gone within two weeks of stopping. That is what puts a second statin first.
- LDL 162 mg/dl, father with a myocardial infarction at 58From 162 to below 100 mg/dl is a reduction of about 40 %, the range of a moderate statin dose. The blood test after eight weeks shows whether it closes the distance.
- Lipoprotein(a) not yet measuredA high value would move her risk category, and with it the goal.
Sources
Built from the studies behind each option and from this chart: the muscle aches of 2024, the LDL, the family history and the medication list. Where a study population differs from her, that sentence stands above the numbers. The order is a proposal with its reasons visible; the decision is the physician's.