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Are PCSK9 Inhibitors Better Than Statins?

Q. I’ve been hearing about new cholesterol drugs that work better than statins. Should I be taking them?

A. Statins have long been the medication of choice for reducing LDL (bad) cholesterol levels and the risk of heart attack. That is still true. But a new class of cholesterol-lowering drugs, called PCSK9 inhibitors, has generated a lot of attention since the first two were approved in late 2015.

There have been questions about how to best use the drugs. But the latest treatment guidelines from the American College of Cardiology offer some clarity.

For people with coronary artery disease—including a history of heart attack, unstable angina, or procedures to clear blocked arteries—statins are still the gold standard. If they fail to reduce LDL levels enough, it might be necessary to add a non-statin drug.

Generally, the first choice should be ezetimibe (Zetia). If ezetimibe is not tolerated, then a bile acid sequestrant might be a good second option.

The PCSK9 inhibitors—evolocumab (Repatha) and alirocumab (Praluent)—should be reserved for patients whose LDL remains stubbornly high despite a statin/ezetimibe combination or who cannot tolerate statin side effects, and a combination of other non-statins falls short in LDL-lowering.

For most people, there is no need to rush for the new drugs. That is partly because little is known about their long-term effectiveness and safety.

Plus, unlike older cholesterol medications, they are taken by injection and are very expensive. The first of the longer-term trials of these drugs should be completed later in 2017.

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