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Dr. Englert:
Hi, I'm Dr. Randy Englert. Here with me today is my colleague, Dr. Matt Malachowski. Today's episode will focus on achieving LDL targets with combination therapy.

Matt, can you comment on why so few of our patients with high-risk disease are able to achieve these low LDL targets?

Dr. Malachowski:
That's a great question, Randy. I think first it is diffusion of responsibilities. I think that depending on where the patient presents, different practitioners are going to identify the problem to initiate treatment. But for these high-risk patients, they're going to be traveling through the health system, and the person that identifies this risk for the patient may not be the same person that is titrating to effect to get these LDL goal levels to where they need to be for therapeutic improvement and decreased risk for the patient.

So this is a scenario where a medical team, your primary care doctors, your specialists in cardiology, and your pharmacy team can really work together to provide that longitudinal support that will ensure that we're not just initiating therapy, but we're titrating to effect, and we're seeing that positive impact on that LDL-C. This is a great scenario where your medical team and your pharmacy team can be working like a pitcher and a catcher who are in sync and can create some great relays down the field to ensure that it's not just that the medication is ordered, it's that we're getting the appropriate therapeutic effect.

Different strategies for driving that LDL-C level to goal. So sequencing statins, making sure that you're using the appropriate dosing based on the patient's risk and diagnosis, adding other oral agents such as ezetimibe, and escalating to some of our injectable medications such as the PCSK9s and other novel agents.

By using these medications sequentially, seeing the impact that it has for the patient, and continuing that escalation not just for therapy initiation but also to ensure we're getting that optimal value on the back end, that will set our patients and our teams up for success.

And having the pharmacy support there to ensure that we're able to provide appropriate copay assistance where possible, provide patient education, and making sure that the patient is adherent to these regimens, that's going to drive these outcomes that we need, and it will ensure that the patient receives that longitudinal adherence that's going to decrease their long-term risk scores.

So there's a lot of opportunity here. There's a lot of small ball at play. Many members of the team that are going to be interacting with these patients, working together, making sure they're tagging the bag, and making sure that at each decision point the person that's most capable to make the right decision for that patient feels empowered to do so. And if everybody plays their part, we can get 3 outs and get out of the inning and make sure that our high-risk patients don't have those negative outcomes that we're trying to avoid.

Dr. Englert:
Those are all great points. I mean, LDL monitoring and intensification, that's what you're highlighting here. Those are really the mechanisms that are going to translate those evidence-based targets, those LDL goals into actual patient benefit. And so monitoring your lipids is one of the ways that we're actually monitoring adherence as well as patient individual variation in response to those medications, whether that variation is due to diet, due to genetics, due to drug-drug interactions, etc. A lipid panel is a way to objectively measure that variation and also monitor your patient for adherence to the medical regimen.

It also helps to overcome the inertia. And so if you are monitoring your patient's lipid panel, that abnormal result that is not at goal is going to trigger the response. If you don't have the data, you're less likely to act and intensify your therapy. Monitoring also ensures that when you do intensify, it's done so timely. So if you are checking your lipid panel on a routine basis at that 4- to 12-week mark after initiation or intensification of therapy and then swapping on over to annual once the patients are at their LDL goal, you're ensuring the patients are adherent and that they remain at their target. And it's really that sustained low LDL, not a single measurement, that's going to drive that long-term benefit.

Dr. Malachowski:
I completely agree, Randy. We have to be intelligent about the monitoring as well. There's a lot of different variables in play here. So if a patient is not to goal, it might be not nonadherence; it might be that they need escalation. So having a great summary, trusting our intuitions, and then working together, socializing this information among your medical partners. What are the new guidelines? What are we doing for patients? And then what can we do as an organization and as a team to get those outcomes? All those are going to play a part in ensuring the patient's success.

Dr. Englert:
Great. Well, I think you kind of wrapped that up right there. So thank you for listening. Remember, even small steps such as checking a lipid panel goes such a long way in terms of helping safety for our patients. Stay tuned for our next discussion.

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