New evidence suggests that two additional cholesterol-lowering drugs should be given to patients who are at high risk of cardiovascular disease.

International experts have concluded that ezetimibe and PCSK9 inhibitors should be given to adults with high levels of ‘bad’ cholesterol who are already taking the maximum dose of statins or those who are intolerant to statins.

The drugs work by reducing the absorption of cholesterol from foods and the production of cholesterol in the body. While ezetimibe comes in tablet form, PCSK9 inhibitors require injections.

The panel favours ezetimibe over PCSK9 inhibitors

The advice is based on new evidence from 14 trials involving more than 83,000 patients, which showed that ezetimibe and PCSK9 inhibitors probably reduce heart attacks and strokes in patients with very high and high cardiovascular risk, but not in patients with moderate and low cardiovascular risk.

While no important side effects were found, PCSK9 inhibitors sometimes resulted in injection site reactions, which the experts say is ‘a burden and a harm’ to many patients.

Since PCSK9 inhibitors are also more expensive than ezetimibe and statins, the panel favours ezetimibe over PCSK9 inhibitors, but says “both would provide important benefits for adults in the high and very high-risk group, but would be of little benefit for adults in the low risk group.”

Some ‘uncertainties’ in the evidence

The panel notes that there are some uncertainties in the evidence underlying this guideline and say their recommendation may be altered as new evidence emerges.

They say clinicians must therefore identify patients’ individual cardiovascular risks and apply these recommendations accordingly.