Management of elevated low-density lipoprotein cholesterol in adults without cardiovascular disease or diabetes

ASCVD: atherosclerotic cardiovascular disease; FH: familial hypercholesterolemia; LDL-C: low-density lipoprotein cholesterol.

* Recommendations for screening are found elsewhere.

¶ We recommend that decisions regarding the initiation of LDL-C interventions be made only after two baseline values have been recorded.

Δ All adults, irrespective of LDL-C, should receive counseling on the benefits of a healthy lifestyle and should be evaluated for the presence of diabetes, hypertension, and smoking.

◊ For more information, refer to the UpToDate topics on the evaluation of patients for familial hypercholesterolemia.

§ Recommendations for the use of risk calculators are found elsewhere.

¥ High-dose statin: atorvastatin 40 to 80 mg once daily; rosuvastatin 20 to 40 mg once daily. For patients who are statin intolerant, or those who are unwilling to start a statin due to fear of side effects, use of non-statin agents can be an alternative. Two agents have been specifically tested and shown to reduce cardiovascular events in primary prevention are ezetimibe and bempedoic acid.

Moderate-dose statin: atorvastatin 10 to 20 mg once daily; fluvastatin 40 mg twice daily; lovastatin 40 to 50 mg once daily; pitavastatin 1 to 4 mg once daily; pravastatin 40 to 80 mg once daily; rosuvastatin 5 to 10 mg daily; simvastatin 20 to 40 mg once daily.

‡ For patients with 5 to <7.5% 10-year ASCVD risk who have LDL-C ≥160 mg/dL, we usually suggest statin therapy.

† In general, we take this step for patients on their highest-tolerated statin dosage. We first add oral ezetimibe 10 mg daily. If LDL-C is still ≥100 mg/dL, we add bempedoic acid (or a fibrate such as colesevelam). Refer to UpToDate for further information.