As expected from a draft document released in July, an expert consensus group of the American College of Cardiology updated its lipid guidelines to boost PCSK9 inhibitors in secondary prevention.
The document, published in the Journal of the American College of Cardiology, focuses on patients with clinical atherosclerotic cardiovascular disease (ASCVD), with or without other conditions. No changes were deemed warranted to the decision pathways and algorithms for use of ezetimibe or PCSK9 inhibitors in primary prevention.
The 2016 document had said it was "reasonable to consider the addition of ezetimibe [Zetia] as the initial agent and a PCSK9 inhibitor as the second agent."
For adult ASCVD patients with a baseline LDL of 70 to 189 mg/dL, the update now says "it is reasonable to consider the addition of either ezetimibe or a PCSK9 inhibitor based on considerations of the additional percent LDL-C reduction desired, patient preferences, costs, route of administration, and other factors."
As to the decision among agents, it added, "Clinicians should preferentially prescribe drugs that have been shown in RCTs [randomized controlled trials] to provide ASCVD risk-reduction benefits that outweigh the potential for adverse effects and drug–drug interactions, and consider patient preferences."
And, for those with comorbidities who require a more than 25% additional lowering of LDL, "a PCSK9 inhibitor may be preferred as the initial non-statin agent."
Also, the update simplified the consideration of net ASCVD risk reduction benefit from considering comorbidity status to being for all patients.
Other changes were to downgrade bile acid sequestrant use to only optional secondary agents for consideration in patients intolerant of ezetimibe and to add diagnostic categories of heterozygous and homozygous familial hypercholesterolemia, based on clinical criteria with and without genetic testing.