Beyond Statins
Statins are no longer the only game
The last decade added a shelf of modern lipid-lowering drugs that hit different targets — useful for people who can't tolerate statins, people who need deeper ApoB lowering, or people with elevated Lp(a) (where only a few options exist at all).
Ezetimibe — cheap, tolerable, additive
Ezetimibe blocks cholesterol absorption in the gut. On its own it lowers LDL-C ~20%. Added to a statin the combination achieves what a higher statin dose would, often with better tolerability. IMPROVE-IT showed adding it to a statin cuts events further — the "lower is better" thesis playing out.
PCSK9 inhibitors — deepest LDL drops
Evolocumab and alirocumab (monthly injections) lower ApoB 50–60% beyond statin. They also lower Lp(a) by ~25% — currently the most accessible Lp(a) therapy. FOURIER and ODYSSEY showed event reductions. Expensive, but generic availability approaching as biosimilars enter the market.
Bempedoic acid + inclisiran — the new layer
Bempedoic acid (oral, once daily) works upstream of statins with no muscle-tissue penetration — useful for true statin-intolerance. Inclisiran (twice-yearly injection) is an RNA-based PCSK9 approach. Both lower ApoB meaningfully; CVD-outcome trials continue maturing.
Match the drug to the situation
Connect each patient scenario to the drug most likely to help.
Key Takeaway
The lipid toolkit now covers statin-intolerance (bempedoic acid), deep ApoB lowering (PCSK9 inhibitors), convenient dosing (inclisiran, twice a year), and cheap combination (ezetimibe). For the first time, Lp(a)-specific therapies are nearing approval. Talk to a lipidologist if you're on a statin and your ApoB is still >80.