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Cholesterol-lowering drugs that are alternatives to statins may become more widely used after a major trial has shown they can stop heart attacks and strokes even in people not thought to be at the highest risk.
The treatments, which include injections that are given twice a month or twice yearly, can also be combined with statins to lower people’s cholesterol further still.
But the UK’s use of these medicines lags behind the latest recommendations from countries such as the US, where new guidelines say people should start having their cholesterol levels tested from the age of 30.
“We need to make sure everybody gets their cholesterol down as quickly as possible and as low as possible,” said Dr Joseph Cheriyan, a heart researcher at the University of Cambridge.
High “bad cholesterol”, also known as low-density lipoprotein (LDL), is one of the major causes of heart attacks and strokes. LDL in the blood can stick to arteries, slowly building up plaques that block off the blood supply to the heart or trigger blood clots.
Statins, available as tablets, work by reducing cholesterol production in the liver. In the UK, they are offered to people who have survived a heart attack or stroke, or who have been found to have high cholesterol, from about the age of 40 onwards.
But since their development, other cholesterol-lowering medicines have also become available, which are useful if people experience side effects such as muscle pain from statins.
Two other kinds of tablet, called ezetimibe and bempedoic acid, work by blocking the absorption of cholesterol from the gut and blocking liver manufacture, respectively.
More recently, several injections have arrived that are even more potent at lowering cholesterol and are seen as a more “aggressive” or intensive therapy, kept for people at the highest level of risk.
These have a different mechanism: making the liver remove more cholesterol from the blood. They lower LDL levels by 60 to 70 per cent, compared with 30 to 50 per cent for statins.
The injections are more expensive, so NHS guidelines say they should be reserved for people who have already had a heart attack or stroke, and cannot tolerate statins because of side effects, or for whom statins aren’t reducing their cholesterol enough.
Now, though, a large trial has shown benefit in 3,655 people who hadn’t previously had a heart attack but did have type 2 diabetes.
The injection, evolocumab, was tested as an addition in people already taking statins and ezetimibe. It lowered their cholesterol levels by a further 50 per cent, compared with those who got placebo treatment.
The UK is lagging behind the latest recommendations from countries such as the US, where new guidelines say people should start getting their cholesterol levels tested from the age of 30 (Photo: fcafotodigital/E+/Getty) Crucially, the drug also reduced by 30 per cent the rate of major events such as heart attacks, strokes or death due to heart disease.
“For over a decade, intensive cholesterol‑lowering has been reserved for patients who already have cardiovascular disease,” said Dr Nicholas Marston, a cardiologist at the Mass General Brigham Heart and Vascular Institute in Boston, who led the trial. “These results demonstrate the benefit of intensive lowering of cholesterol earlier.”
The results may nudge UK doctors into being more proactive about cholesterol-lowering, said Professor Naveed Sattar, a heart specialist at the University of Glasgow, who was also involved in the trial. “I think this paper will lead to a few more people getting [injections]. But the biggest hit is going to be more people thinking: ‘Instead of just giving a statin, I should also be thinking about ezetimibe’. It will increase the use of cholesterol-lowering therapy across the board.”
The results were published in the journal JAMA last week.
New guidelines from 11 US medical societies, released earlier this month, say people should start having their cholesterol measured from the age of 30. “I think we should be considering following the American advice now,” said Cheriyan. “High LDLs over a lifetime increase your risk.”
The US guidelines also recommend that higher doses of statins or other drugs should be taken until the person’s LDL has been brought down to 1.4 millimoles per litre (mm/L). In the UK, the target is 2.0 mm/L. And the injections may only be given if someone’s LDL is higher than 3.5 mm/L, while taking the maximum doses of statins and ezetimibe.
“The UK criteria are extremely conservative,” said Professor Ian Graham, a cardiologist at Trinity College Dublin, who was not involved in the study.
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