Treat to Target or Use High-Intensity Statins Across the Board?

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The MD Magazine Peer Exchange “Amassing the Clinical Evidence for Optimized Dyslipidemia Management: Vitamin D, Long-Term Statin Outcomes, and PCSK9 Inhibition” features expert insight and analysis of the latest information on managing hypertension and hyperlipidemia, and in-depth discussion on the use of PCSK9 inhibitors in practice.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

• Christie Ballantyne, MD, Co-director of the Lipid Metabolism and Atherosclerosis Clinic at The Methodist Hospital, Director of the Center for Cardiovascular Disease Prevention at the Methodist DeBakey Heart Center, and the Chief of Cardiology at Baylor College of Medicine
• Keith C. Ferdinand, MD, Immediate Past Chair of the National Forum for Heart Disease and Stroke Prevention, and Professor of Clinical Medicine at the Heart and Vascular Institute at Tulane University School of Medicine
• Jennifer G. Robinson, MD, MPH, Professor in the Departments of Epidemiology & Medicine and Director of the Prevention Intervention Center, Department of Epidemiology at the College of Public Health, University of Iowa
• Karol E. Watson, MD, PhD, Professor of Medicine and Cardiology, Co-director of the UCLA Program in Preventive Cardiology, and Director of the UCLA Barbra Streisand Women’s Heart Health Program

When it comes to statin therapy, what is the proper way to prescribe them? Should physicians prescribe to a target or should they default to a high-intensity statin?

Dr. Robinson noted that the trials discussed in the previous segment were “done in people with cardiovascular disease who got a high-intensity statin regardless of their baseline LDL. So that’s what we recommend people do.”

She said this recommendation does come with a caveat: it only applies for patients up to age 75, for whom moderate-intensity statin therapy is recommended instead. “We want people to be on statins, prefer high-intensity statins, but safety should be foremost.”

Although the evidence points to high-intensity statin therapy being effective, the question was raised by Dr. Salgo as to whether patients who are concerned about side effects would be better starting off at a much lower dosage.

Dr. Watson said that with the way the trials were conducted, it makes the most sense for the guidelines to recommend high-intensity statin therapy, especially for high-risk patients (eg, patients who have suffered a myocardial infarction).

The question then becomes how to handle long-term therapy in patients who experience significant side effects. “We don’t want you to abandon your statin in that patient because they had side effects. Try to get them on a statin, and if you need to go down to moderate intensity, you do that. But maybe you need to check Vitamin D. Maybe you need to consider down titrating the statin and adding ezetimibe. A lot of different strategies are appropriate,” he said.

The problem with starting patients at a lower dose of statin is that physicians don’t really titrate, despite assertions to the contrary, said Dr. Ferdinand. Given that reality, “I think it’s more reasonable to attempt a high intensity statin. And then drop back if you have to, recognizing that the differences across the doses for side effects and complications is really not as big as you would think,” he said.