Suboptimal LDL-C in FH Patient Despite Use of Three Cholesterol-Lowering Meds

Some FH patients may have suboptimal LCL-C despite treatment with PCSK9 inhibitors, statins and ezetimibe.

At the ACC.18 Scientific Sessions & Expo, researchers presented a case of a man with familial hypercholesterolemia (FH) and non-ST elevation myocardial infarction who was referred for lipid management to reduce his persistently high low-density lipoprotein cholesterol (LDL-C). 

Despite treatment with atorvastatin 80mg, the 34-year-old man presented with an LDL-C of 252mg/dL. He was started on ezetimibe 10mg daily and was later initiated on evolocumab 140mg bimonthly, but his LDL-C still remained elevated at 150mg/dL even on all three agents. While his LDL-C level was higher than the target goal of 70mg/dL, it remained below the coverage requirement for lipoprotein apheresis. As a result, clinicians considered adding mipomersen as additional treatment. 

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The authors write that while the availability of proprotein convertase subtisilin kexin type 9 (PCSK9) inhibitors has reduced the use of mipomersen, and lomitapide in FH patients, these treatment options may still benefit those who require additional LDL-C reduction. “The combination of either of these drugs with PCSK9 inhibitors has not been studied in randomized clinical trials,” said lead author, Isha Verma, from Hartford Hospital, Hartford, CT. “Case reports and case series might contribute to the medical literature in this subject and guide medical therapy, until clinical trials are devised in this patient population.”


Verma I, Fernandez AB, Thompson P. Familial Hypercholesteremia: When Statins, Ezetimibe & PCSK9 Inhibitors Are Not Enough. Presented at: ACC.18 Scientific Sessions & Expo. March 10–12, 2018; Orlando, FL. Session: 1241-117.