An approximate solidifying recommendation is:
For patients with severe hypercholesterolemia defined by baseline LDLc ≥190 mg/dL; target LDLc is <100 mg/dL. To achieve this target, patients could receive the following medications in the following order: max statin ± ezetimibe ± BAS ± PCSK9 inhibitor.
If baseline TGs >300 mg/dL, do not use BAS
If baseline LDLc is very high, >220 mg/dL, then target LDLc could be <130 mg/dL
Severe Hypercholesterolemia (LDLc ≥190 mg/dL)
In patients age 20-75 with an LDLc ≥190 mg/dL:
Maximally tolerated statin therapy is recommended
If <50% LDLc reduction is achieved while receiving maximally tolerated statin therapy and/or have an LDLc ≥100 mg/dL, ezetimibe therapy is reasonable.
If <50% LDLc reduction is achieved and have fasting Triglycerides ≤300 mg/dL while taking maximally tolerated statin and ezetimibe therapy, the addition of a BILE ACID sequestrant may be considered.
In patients age 30-75 with heterozygous FH and with an LDLc ≥100 mg/dL while taking maximally tolerated statin + ezetimibe therapy, the addition of a PCSK9 inhibitor may be considered.
In patients age 40-75 with a baseline LDLc ≥220 mg/dL and who achieve an on-treatment LDLc ≥130 mg/dL while receiving maximally tolerated statin + ezetimibe therapy, the addition of a PCSK9 inhibitor may be considered