NLA GUIDELINES Bundle (free trial)

35 Table 14. Recommendations Recommendations Strength Quality Fibrates and prescription omega-3 fatty acids are first-line drug choices for patients with TG ≥500 mg/dL, although consideration may be given to using statin therapy as a firstline drug in patients with TG 500–999 without a history of pancreatitis. E Moderate In patients with elevated TG (200–499 mg/dL) on maximum tolerated statin therapy who are at their LDL-C goal but not their non–HDL-C goal, the addition of therapies that primarily lower TG and VLDL-C (fibrates, high-dose omega-3 fatty acids) may be considered to help achieve atherogenic cholesterol goals. Subgroup analyses from cardiovascular outcomes studies provide suggestive evidence of reduced ASCVD event risk with the addition of a TG-lowering agent to statin therapy, particularly in patients with the combination of elevated TG and low HDL-C. B Moderate For patients not at goal atherogenic cholesterol levels on maximal tolerated statin therapy, consideration should be given to adding non-statin lipid-altering therapy to ongoing statin therapy for further lowering of atherogenic cholesterol, as long as the patient has sufficient ASCVD risk to warrant it, and the expected treatment benefit outweighs the risk for adverse consequences. B Moderate Recommended statin combination therapies to consider for further lowering of atherogenic cholesterol are, in the following order: • First – ezetimibe 10 mg every day • Second – colesevelam 625 mg 3 tablets twice a day (or 3.75 g powder form every day or in divided doses) • Third – extended release niacin titrated to a maximum of 2000 mg daily. B Moderate Until cardiovascular outcomes trials are completed with PCSK9 inhibitors, a these drugs should be considered primarily in: 1. patients with ASCVD who have LDL-C ≥100 mg/dL (non- HDL-C ≥130 mg/dL) while on maximally-tolerated statin (±ezetimibe) therapy and 2. heterozygous FH patients without ASCVD who have LDL- C ≥130 mg/dL (non-HDL-C ≥160 mg/dL) while on maximally- tolerated statin (±ezetimibe) therapy. B Moderate In addition, PCSK9 inhibitor a use may be considered for selected high risk patients with ASCVD (e.g., recurrent ASCVD events) who have atherogenic cholesterol levels below the specified values, but above their treatment goals (i.e., LDL-C ≥70 mg/dL [non-HDL-C ≥100 mg/dL]). Such use would be based on clinical judgment, weighing the potential benefits relative to the ASCVD event risk and the risks and costs of therapy. C Low PCSK9 inhibitor a use may also be considered in selected high or very high risk patients who meet the definition of statin intolerance (as previously defined by the NLA Statin Expert Panel) and who require substantial additional atherogenic cholesterol lowering, despite the use of other lipid lowering therapies. Such use would be based on clinical judgment, weighing the potential benefits relative to the ASCVD event risk and the risks and costs of therapy. C Low a PCSK9 inhibitor NOT recommended for children.

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