What should I do if the maximum dose of statins still cannot bring my cholesterol level up to the target?

A friend told Huazi that he had coronary heart disease and the doctor asked him to take statins to protect his cardiovascular system. He had already taken the maximum dose of statins specified in the instructions, but his low-density lipoprotein cholesterol (LDL-C) level still did not reach 1.8mmol/L. What should he do? Can he continue to increase the dose?

Huazi told him that for people with coronary heart disease, it is best to control the LDL-C level below 1.8mmol/L. However, statins should not be taken in excess, but they can be considered in combination with other lipid-lowering drugs.

1. Why is it necessary to meet the LDL-C level standard? The mechanism of atherosclerosis is that under the influence of factors such as smoking, hypertension, diabetes, and hyperlipidemia, the intima of the arteries is damaged. The LDL-C in the blood will enter the intima of the arteries from the damaged area and then be swallowed by macrophages, converted into foam cells, and deposited together to form the lipid core of the plaque.

The higher the LDL-C level in the blood, the faster the plaque progresses. As long as the LDL-C level can be lowered, the progression of plaque can be inhibited. Studies have confirmed that when the LDL-C level drops below 1.8mmol/L, the free LDL-C in the arterial intima will be reversed back into the blood and transported back to the liver for decomposition.

When using statins, the LDL-C level is the standard for measuring whether the statins are effective. For people who have not suffered from cardiovascular and cerebrovascular diseases such as cerebral infarction, myocardial infarction, coronary heart disease, etc., the LDL-C level needs to be controlled below 2.6mmol/L, which can delay the progression of the disease and prevent the occurrence of the disease.

However, for people who have already developed cardiovascular and cerebrovascular diseases, it is necessary to control the LDL-C level below 1.8mmol/L to promote plaque reversal and reduce the degree of arterial stenosis. Current research has confirmed that the lower the LDL-C level, the better the effect on plaque reversal. For some people with serious conditions, it may be necessary to reduce the LDL-C level to below 1.4mmol/L.

2. The "plus 6 principle" of statins Statins have a significant effect on lowering LDL-C. Intermediate-acting statins can reduce LDL-C levels by 30% to 40%, and potent statins can reduce LDL-C levels by more than 50%. However, when taking medication, all statins have a "plus 6 principle". That is, when the dose of statins is doubled, the reduction in LDL-C levels can only increase by 6%.

If you double the dose of statins, the risk of adverse reactions will increase significantly, so statins should not be taken in excess. In addition, Chinese people are more sensitive to statins and are more likely to have adverse reactions, so large doses of statins are generally not recommended.

3. Combination of statins with other drugs If the LDL-C level cannot reach the target after using statins, if there are no obvious adverse reactions, you can try to increase the dose until the maximum dose. If it still cannot reach the target, you can consider combining it with other lipid-lowering drugs.

A common choice is to use a cholesterol absorption inhibitor (ezetimibe) in combination, which inhibits the absorption of cholesterol by the villi of the small intestine, and can further reduce LDL-C levels by 20% to 30% on the basis of statin control without increasing adverse reactions.

The common practice now is to use moderate doses of statins in combination with ezetimibe, and try to avoid the use of large doses of statins to prevent adverse reactions.

If ezetimibe still cannot effectively lower LDL-C levels, another option is to use it in combination with a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor, which can continue to reduce LDL-C levels by more than 60% on the basis of statins.

PCSK9 in the human body can bind to low-density lipoprotein receptors (LDL-R) to reduce the decomposition of LDL-C. After using PCSK9 inhibitors (evolocumab, alirocumab, etc.), the binding of PCSK9 to LDL-R can be inhibited, thereby enhancing the decomposition of LDL-C and reducing LDL-C levels.

PCSK9 inhibitors have a strong effect in lowering LDL-C and have few adverse reactions. Their disadvantage is that they are expensive and will greatly increase patients' medication costs.

To sum up, when taking statins, LDL-C needs to be controlled to meet the standard in order to play the best cardiovascular and cerebrovascular protective role. If statins alone cannot achieve the LDL-C level, you can consider combining them with cholesterol absorption inhibitors or PCSK9 inhibitors to continue to lower LDL-C levels. The drug must be used under the guidance of a doctor. If you have any questions about the use of the drug, please consult a doctor and pharmacist. I am pharmacist Huazi, welcome to follow me and share more health knowledge.