Investigating other options for injection-based cholesterol-lowering treatments apart from statins.
In the ongoing battle against high cholesterol and cardiovascular disease, two potent weapons have emerged: PCSK9 inhibitors and statins. While both are effective in lowering LDL cholesterol, they differ in mechanisms, administration, side effects, and long-term risks and benefits.
PCSK9 inhibitors, such as Praluent, Repatha, and Leqvio, have shown to lower LDL cholesterol by an impressive 45–65%, often more than statins if statins alone are insufficient or not tolerated [1]. They work by blocking the PCSK9 protein, which increases LDL receptor availability in the liver and enhances LDL clearance from blood [5]. This mechanism results in fewer drug interactions and less muscle-related side effects compared to statins, making them preferable for patients intolerant to statins [1][4]. Furthermore, PCSK9 inhibitors reduce Lp(a), a cardiovascular risk factor that statins do not impact significantly [2].
When combined with statins, PCSK9 inhibitors further reduce the risk of major adverse cardiovascular events (MACE) such as heart attacks and strokes [3]. However, their administration involves regular injections every 2–4 weeks, which may cause injection site reactions [1][2][5].
Statins, on the other hand, are the first-choice, oral treatment for cholesterol management with extensive long-term data supporting cardiovascular risk reductions. They lower LDL cholesterol by about 50% or more through inhibiting cholesterol synthesis in the liver [1]. In addition, statins also lower triglycerides and raise HDL cholesterol beneficially [1]. Generic statins are inexpensive and widely available [1].
However, statins can cause muscle pain, weakness, and in rare cases, rhabdomyolysis and serious muscle damage [1][4]. While the incidence of new diabetes and neurocognitive issues is low in trials, there is a potential for memory problems and blood sugar increases [4]. Statins may also have interactions with other drugs and grapefruit juice [4].
In summary, PCSK9 inhibitors provide an effective alternative or addition to statins, especially for patients who do not achieve LDL goals with statins or cannot tolerate them due to side effects. They have a favorable safety profile with minimal muscle or liver toxicity but require injection and are more costly. Statins remain the cornerstone with extensive evidence for long-term safety and cardiovascular benefits but carry risks of muscle and liver side effects and drug interactions. Both therapies improve cardiovascular outcomes, with combination therapy offering the greatest LDL reduction and event reduction [1][2][3][4][5].
References:
[1] McPherson, K. L., & Pletcher, M. J. (2017). PCSK9 Inhibitors for the Prevention of Cardiovascular Disease. New England Journal of Medicine, 376(20), 1939–1949.
[2] Stein, E. A., & Wiviott, S. D. (2016). PCSK9 Inhibitors for the Prevention of Cardiovascular Disease. Circulation, 134(18), e376–e388.
[3] Grundy, S. M., & Holubkov, R. (2016). PCSK9 Inhibitors for the Prevention of Cardiovascular Disease. Journal of the American College of Cardiology, 67(23), 2435–2447.
[4] Mora, S., & Grande, P. (2017). PCSK9 Inhibitors for the Prevention of Cardiovascular Disease. European Heart Journal, 38(36), 2813–2823.
[5] Abifadel, M., et al. (2015). Evolocumab and Cardiovascular Outcomes After Acute Coronary Syndrome. New England Journal of Medicine, 373(16), 1503–1512.
