Transcript
Announcer:
This is Heart Matters on ReachMD. On this episode, Dr. Ann Marie Navar, an Associate Professor of Cardiology at the University of Texas Southwestern Medical Center, will share guideline updates and management strategies for hypercholesterolemia. Let’s hear from her now.
Dr. Navar:
I was part of the 2026 Multisociety Lipid Guideline Writing Committee, and one of the things that we were really excited about was reinstituting LDL cholesterol goals. And now I think it's going to be a lot easier for clinicians to have a number that they share with their patient and say, "This is the goal." We are all goal-oriented. We like making and checking boxes. And so now that we've given people a number, we actually very explicitly in the guidelines say, "Use the drug that's going to get the patient to goal." So we don't do a lot of preferentially choosing which medication after statins to use because we really want clinicians to work with their patients and use the drug that's going to get people to goal that people are actually going to be willing to take.
So I think the landscape is actually simplified now for people with ASCVD. Almost everybody is considered very high risk. The LDL goal is 55. For other high-risk people—high-risk diabetes, coronary calcium—LDL goal is 70. And then after a statin, we got to use whatever we can to get people there.
So then the question comes up, what's the next choice? And we have a few currently available therapies. Ezetimibe and bempedoic acid work. Both have cardiovascular outcomes data, but the relative magnitude of LDL lowering on top of a statin is modest. Even in combination, those two are going to get you 20 to 30 percent more LDL lowering on top of a high-intensity statin, and a lot of people need more than that.
With the PCSK9 inhibitors and the monoclonal antibodies, evolocumab and alirocumab, we get 60-plus percent LDL lowering, which is great, but they're injectable. And although patients are actually pretty okay with injections, it's actually, I think, a challenge for busy clinicians. So in my lipid clinic, I have 40 minutes to prescribe medication, talk about it, and show people how to use it, but a primary care doc that's got a 20-minute visit has a lot of things to do. And I think the injection can take a little bit more time, and when we look at uptake of injectable therapies in our primary care colleagues, it's in the single digits in terms of what percent of primary care clinicians are using it. And even amongst cardiologists, we found a couple years ago that about 40 percent of cardiologists are not using these drugs.
And so we've got the tools and people just aren't using them. The price has come down for these, payer coverage has improved, and some PBMs have even dropped the prior auth, but we just have not seen the needle move in terms of getting people to use them to increase lipid-lowering therapy. So this is actually where I'm most enthusiastic for enlicitide, because I think it's just psychologically easier for clinicians to prescribe a pill than it is a shot. And for patients who are maybe on the fence about wanting more cholesterol lowering, it's a little easier to accept another pill versus adding an injection that's every other week.
So where I'm hopeful is certainly for the group of people who are needle-phobic or who just don't want an injection. But I'm also hopeful that my colleagues who have been perhaps reluctant to start prescribing the monoclonals may be a little bit more comfortable prescribing enlicitide. And I'm actually hopeful that that ends up opening the door for them to be using more than just enlicitide. Maybe once you get used to prescribing enlicitide, it's not as big of a deal to start prescribing evolocumab as well. So I think we can have more people using non-statins and maybe even have more people using more non-statins once we have more options available.
Announcer:
That was Dr. Ann Marie Navar sharing updates in hypercholesterolemia management. To access this and other episodes in this series, visit Heart Matters on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
