Debate About LDL Targets

Special guest Steven E. Nissen, MD, MACC, the Chief Academic Officer at the Heart and Vascular Institute, Lewis and Patricia Dickey Chair in Cardiovascular Medicine, and Professor of Medicine at the Cleveland Clinic Lerner School of Medicine at Case Western Reserve University joins us to talkabout LDL targets.

Listen in as they debate whether to aim for a specific goal for LDL cholesterol.

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Stephen Carek, MD, CAQSM, DipABLM, Clinical Assistant Professor of Family Medicine, Prisma Health/USC-SOMG Family Medicine Residency Program at the USC School of Medicine Greenville
• Andrea Darby Stewart, MD, Associate Director, Honor Health Family Medicine Residency Program and Clinical Professor of Family, Community & Occupational Medicine at the University of Arizona College of Medicine - Phoenix
• Anthony A. Donato, Jr., MD, MHPE, Associate Director, Reading Health System Internal Medicine Residency Program and Professor of Medicine at the Sidney Kimmel Medical College at Thomas Jefferson University
• Craig D. Williams, PharmD, FNLA, BCPS, Clinical Professor of Pharmacy Practice at the Oregon Health and Science University

For the purposes of disclosure, Dr. Steven Nissen reports relevant financial relationships [cardiology] with AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Esperion, Medtronic, MyoKardia, New Amsterdam Pharma, Novartis, Pfizer, Silence Therapeutics (grants/research support).

The other speakers have nothing to disclose. All relevant financial relationships have been mitigated.

Pharmacist’s Letter offers CE credit for this podcast. Log in to your Pharmacist’s Letter account and look for the title of this podcast in the list of available CE courses.

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The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter: 

• FAQ: Cholesterol Guidelines (United States)

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Transcript

Narrator 0:04

Welcome to Medication Talk, the official podcast of TRC Healthcare, HOMA Pharmacist Letter, Prescribers Letter, RX Advanced, and the Most Trusted Clinical Resources. On today's episode, we'll listen in as our expert panel debates whether to aim for a specific goal for LDL cholesterol. Our guest today is Dr. Stephen Nissan from the Cleveland Clinic. You'll also hear practical advice from panelists on TRC's editorial advisory board. Dr. Stephen Carrick from the USD School of Medicine Greenville. Dr. Andrea Darby Stewart from the University of Arizona College of Medicine Phoenix. Dr. Anthony Donato from the Reading Health System. And Dr. Craig Williams from the Oregon Health and Science University. This podcast is an extract from TRC's Emerging Recommendations panel webinar. Each month, experts and frontline providers discuss current medication therapy topics and practical recommendations to include in TRC's letter articles. The full webinar originally aired on May 18, 2023.

CE Narrator 1:03

And now, CE information.

Narrator 1:07

Pharmacist Letter offers CE credit for this podcast. Please log into your pharmacist letter account and look for the title of this podcast in the list of available CE courses. For the purposes of disclosure, Dr. Steven Nitson reports a relevant financial relationship by receiving grants or research support from AB, Amgen, AstraZeneca, Bristol Myersquid, Eli Lilly, Esperion, Medtronic, Myocardia, New Amsterdam Pharma, Novartis, Pfizer, and Silence Therapeutics. The other speakers you'll hear have nothing to disclose. All relevant financial relationships have been mitigated. Now, let's join TRC editor, Dr. Laurie Dickerson, and start our discussion.

Lori Dickerson 1:47

And we're talking about this now because the debate continues about whether to aim for a specific LDL goal. And Steve, to get us started, let's just talk a little bit about the debate surrounding the LDL goals and how it's evolved into this blended approach over the years.

Steven E. Nissen 2:04

Well, what happened here is that in 2013, a major tectonic shift occurred in the guidelines. And, you know, for reasons that I still have trouble understanding, it was decided that it was no longer necessary to have LDL targets. And that really that the best evidence was to kind of give a statin and not worry about so much about what the LDL goal should be. I referred to this at the time as a fire and forget strategy. But the problem is many people, and I must say that I'm in the same in this category, have looked at the data over the years, and the evidence is just overwhelming that for most patients, a lower LDL is associated with lower event rates. And the higher risk you are, the more you want to get LDL to low levels. And back and forth, this debate has raged with both sides digging their heels in and kind of refusing to budge.

Lori Dickerson 3:16

And multiple sets of guidelines from different organizations just really making this pretty muddy out there for folks, right?

Steven E. Nissen 3:23

Indeed. And you know, the guidelines have not really been in synchrony. And I what I've said that many times is why do we need so many guidelines? Do we need the US Preventive Services Task Force and the ACAHA? The European guidelines have targets, the US guidelines don't. The Canadian guidelines are different. And I'm afraid that it's confused a lot of the prescribers and patients, and it's led to a lot of perhaps not very good treatment.

Lori Dickerson 3:53

So we're going to talk about some of the evidence here and try to come to a consensus about a practical approach to you know blending, blending all of this evolving strategy. So, Steve, let's actually next talk about the evidence supporting LDL targets and this blended approach that we have here. Yes.

Steven E. Nissen 4:12

Well, of course, the evidence is accumulated. We've got have probably more evidence on LDL cholesterol-lowering drugs than almost any area of medicine. If you just look at the statin trials alone, it's enormous. You add to that these very large studies with PCSK9 inhibitors. And then you have evidence using intermediate markers. And you know, I did some of those studies. Some of you may remember if you're old enough, uh, a trial I did going way back 20 years ago called the reversal trial, where we targeted lower LDLs and showed that lower LDLs reduced the progression of disease. And later in a trial known as the asteroid trial published in JAMA, we showed that if you got LDL below about 60 on balance, you saw regression of disease measured using intravascular ultrasound. So you've got all this evidence about lower targets. Um, and that's true, by the way. This statement that you make here is absolutely marvelous because it's right. If you look at starting LDL, it doesn't seem to matter. For any degree of reduction in LDL, uh, say one millimole or 38.7 milligrams per deciliter, the reduction in morbidity is the same. And so it doesn't seem to matter where you start.

Craig D. Williams 5:40

Steve says is absolutely right. Uh letters add a couple thoughts, switch up to this up here that yeah, that's all uh you know, great background for it. And then a tectonic shift that occurred in 2013 was kind of guidelines are being high maybe hyper evidence-based, and they point out that the studies we base the guidelines on before that were mostly you know drug trials, randomized different therapies, not randomized LDL goals, and so they they change the language, but it has been very confusing for all of us in practice since then, which is unfortunate. But another thing I would add to this is this it's altitude. If if a patient develops atherosclerosis, it does not matter what LDL they have, it's too high for them. And starting a statin is great to lower events. It's a little bit different talking about I'm on a statin already and my LDL is X, what's the evidence for further titration to get it lower? Because there's some diminishing returns, it's a more curved linear relationship across the population. And and so it's just the setting is a right statement for definitely initiate statins is certainly for secondary invention in people, regardless of LDL. That's a little bit different though than what target should I use if I'm titrating drugs or using multiple drugs in a population.

Lori Dickerson 6:49

Great summary. And just to reiterate the data we have as we stated in our article, the data comparing specific LDL targets are limited, but statins reduce cardiovascular risk, even with a baseline LDL under 70 milligrams per deciliter, plus adding a zetomib or PCSK9 inhibitor for statin patients at very high risk while lowering LDL to about 55 milligrams per deciliter or less can further reduce cardiovascular risk. And so that's our evidence summary. And Andrea, I wanted to call on you now to just get your input on how this evolving approach between statin target doses and LDL goals has impacted your management in primary care.

Andrea Darby Stewart 7:27

Well, to be perfectly frank, um, since my job is mostly primary prevention, and then in those patients who've had events, um, secondary prevention and collaboration with my cardiology colleagues, um, what I have appreciated about having a target for dose of statin rather than LDL is that I am able to do exactly what Steve said. I can place somebody on a statin, it says their adherence to that, and then have a reasonable expectation that in primary prevention I'm helping them reduce their risk for heart disease. Um, certainly for those patients who have already had events, I don't have any issues at all with driving their LDL as low as possible. Um, I do um worry about the number of numbers that we continue to have to manage and think about across ambulatory primary care. Um, and frankly was grateful for something where I could assess a patient intermittently, potentially reduce the cost to the system by not checking a lipid panel on an annual basis when I really wasn't making much changes unless somebody wanted to come off of the medication or I was concerned about adherence. And I've got lovely markers on my EHR that at least tell me the fill rate. And again, there's no street value to a statin, so I doubt that anybody who is has a hundred percent fill rate is you know selling that to their, you know, to their child or their cousin. Um so I I'm ambivalent about this um change in recommendation, certainly not for secondary prevention, but um I would love to have some convincing from the group that from a primary care standpoint I should spend my um my limited time um managing to a number here rather than um looking at other um issues and factors that could impact cardiovascular health.

Steven E. Nissen 9:19

So, Andrea, you make a very good point, and I think you're making an important distinction between secondary prevention and primary prevention, where, as I said kind of right at the beginning, I think it's important that we have a gradation of risk. And the higher the risk the patient, the more intensively we want to lower their LDL. Now, it's also important to state that the Europeans looked at the very same evidence that the U.S. guideline writers looked at, and they came up with a target for very high-risk patients of 55 milligrams per deciliter. They kept the targets, they lowered the targets, looking at the same evidence. And so it is hard for people to understand how thoughtful uh people can look at the same evidence and come to very, very different conclusions. And, you know, I think that Europeans got it right, I think the US guidelines got it wrong. Now, for primary prevention, the evidence that going to super low LDL levels is limited. But there is something that everybody should understand. Although the absolute benefit is a little bit more modest in high-risk primary prevention, the actual hazard ratio and the number needed to treat is actually lower in primary prevention. And I would cite to you the Hope 3 trial and the Jupiter trial, which are the really the two trials in the last 15 years that looked at that question. And in both cases, there were really big benefits. Jupiter, you will recall, had a benefit on mortality in primary prevention, albeit in patients that were selected because of a high C-reactant protein.

Lori Dickerson 11:14

Great summary there too, Steve and Andrea. I appreciate your uh you know perspective and how this does sort of muddy the water. Um, and so I want to come back to some more of the evidence and then try to come to our recommendations and see um how we can make them as practical as possible. And so uh we next say in the article to continue to start a statin at target intensity and then recheck the LDL four to 12 weeks later and at least once a year. And so I think we've um you know all brought up the importance of starting a statin at target intensity, and uh then I guess the question would come in about when to recheck and um and of course the cost that you mentioned associated um with rechecking Andrea. And so, in generally speaking, Steve, uh, would you agree with that rechecking uh at four to 12 weeks later after starting, and then as a general rule, at least once a year?

Steven E. Nissen 12:11

That's what I do. Um, and four weeks is actually uh enough. You know, I I did want to say something here about cost, though. Okay, these guidelines began because statins were initially fairly expensive drugs. And now some of the pharmacies in our area, I don't know if it's happening in your other areas, they're actually making the statins free. They don't charge for statins, you can get them for free. And so the guidelines were originally developed because they wanted to make sure that with a costly uh therapy, that the patients that would most benefit would be given given the therapy. Now we're at a situation where the drugs are essentially free, and so the really the only major downside is this for the very rare adverse effects, which are not to be diminished, but you know, a little bit increase in diabetes, and and that's dose-dependent, of course, as well. And um, you know, some risk of muscle-related and other related adverse effects.

Andrea Darby Stewart 13:21

Got it. Okay, well, you and just it just as a as a prelude to our conversation next month, um, I'm less worried about the cost of the medication because absolutely um uh the cost of the medications has gone down dramatically. Um, but my patients have high deductible health plans. They are paying out of pocket for these lab studies, and the cumulative cost to the system uh has to be something that we consider. And and I would love to see somebody do some type of balanced um uh assessment of we charge this much money for literally the phlebotomist and then the lab draw, and we're doing that at four weeks and or 12 weeks and checking their CMP because we uh you know have a very vague recommendation for when to assess liver function tests, and then we ask the um you know the patient to bear the burden of that cost, and I just I think that we need to be cognizant of that as well.

Steven E. Nissen 14:22

Very good point. By the way, I I don't I assume everybody knows that FDA no longer recommends checking liver enzymes in patients on statins unless you have some other reason to do so. So we can take that cost out of the system. Does anybody know what a lipid panel actually costs?

Lori Dickerson 14:42

Good question, Steve. I don't know what the charges to the patient these days.

Steven E. Nissen 14:45

Yeah.

Lori Dickerson 14:49

Three dollars, Andy says. Interesting.

Andrea Darby Stewart 14:51

It depends on the cost sharing for your insurance and where you get it done. And it also depends on the billable rate that goes out from your organization to the insurer, um, as well as the percentage that the insurance is covering for the individual.

Craig D. Williams 15:06

Yeah, that's I have a lot of uh sympathy for what I work with a large group of primary care fighters and a lot of sympathy for what Andrew is saying in terms of just the everything that's being trying to be managed, and the thing that's changed besides statins have gotten cheaper, but polypharmacy has absolutely gotten worse in the last 10 to 12 years. Yeah, it's three blood pressure medicines and three biodies medicines and two heart failure medicines. And I think the other piece behind all this, and I don't know if to work it in here, Lori, is that you know, unlike treating hypertension and having maybe four good classes of drugs, it's once you've optimized the statin, as we'll get to there's some debate. What that I mean, a zetomide, yeah, it's pretty good, but it's not like we have two or three other classes of drugs that are statin-like in their efficacy and their low side effect profile. We can kind of do a lot of picking and choosing among drugs. It becomes a little bit academic when you get an LDL of X. What do you want to do if you've optimized the statin? And I think that's a piece that deserves a bit of conversation.

Steven E. Nissen 16:01

One thing that needs to be factored in are risk-enhancing factors. And, you know, uh maybe this is a little bit controversial and I have a certain perspective, but you know, I am checking lipoprotein little A more often when people come in and they say, gosh, I got a terrible family history of coronary heart disease, and they're on the borderline, maybe their LDL is not all that high. And sure enough, you get a lipoprotein little A and it is uh really, really high. Or maybe they've gone out and got a coronary calcium scan done, and they come in and they're scared to death because their coronary calcium score is very, very high. And so we can't look at this as LDL is the sole reason for treat. All the other risk factors people have their diabetes, their blood pressure, smoking, and with all of those things, then we can target more intensive therapy on those that are most likely to be.

Lori Dickerson 17:00

And so with that, Steve, I want to uh look at some of our specific recommendations here. And we do have a chart on the screen uh now for folks to see where we have broken up the groups into cardiovascular risk as very high, high, or intermediate. And we've given some examples and we've given an example of this blended approach to uh percent reduction and in LDL as well as a number to aim for. And so to start us off at the top, we talk about the folks with very high cardiovascular risk, so multiple cardiovascular events or a prior cardiovascular event plus multiple risks, which could include some that you've just mentioned. And so here we've noted to aim for a greater than 50% reduction in LDL and to get to less than 55. And so, Steve, what are your thoughts about that blended approach as sort of a ballpark aim for our viewers?

Steven E. Nissen 17:49

Very thoughtful and spot on. I mean, I think that this is exactly what I meant from the outset when I said, look, we've got to grade our treatment intensity to the underlying risk for the patient. And that you've done that here.

Lori Dickerson 18:02

And so then if we walk that forward, uh the high cardiovascular risk would be the next category again, and they could have had just a prior cardiovascular event, but not very high risk, or had a 10-year cardiovascular risk or greater than 20%. So that would be a high risk primary prevention patient. And so there we're looking for an LDL at less than 70 milligrams per deciliter, again, still with that 50% reduction. And so are we still spot on there with what you're what you're aiming for and where you see this going?

Steven E. Nissen 18:31

You know, it's almost exactly how I practice, really. I mean, uh, you know, a lot of people were targeting less than 70 unless they're very high risk, in which case it's less than 55.

Lori Dickerson 18:43

And then, of course, our intermediate group here we have is a 10-year cardiovascular risk of 7.5%, 20 less than 20%, and then we're aiming for 30% reduction in an LDL of less than 100. And and Craig, I just wanted to hear from you too, what you're thinking as you're looking at at this chart and and these recommendations. Is this consistent with what you're you're teaching in your practice?

Craig D. Williams 19:03

Yeah, I think though you're gonna, I mean, you're hearing a little bit of different perspective on this call for this the specialist versus non-specialists. So I think to get to 55, we're comfortable adding a ZMIB to an optimized statin if we don't like our number. And and to a lot of us, and to me included, I'm often more interested in checking LDL as a marker for compliance of statin, and to see if I'm at a level that I'm really unhappy at, as opposed to exactly where I'm happy. So if I have you on a good dose of a statin and your high-risk prime prevention or stable CAD, no resnaphtherosclerosis, and you I've optimized your statin and your LDL's 105 or 95, there's room for some discussion there, especially if they actually if the patient still smokes and they're getting no exercise and they're there's other places to maybe go after as opposed to this. But if I'm really comfortable using PCS9 inhibitors and I manage that insurance well, and there's tools to get here, but they're not real readily easily deployed, I think, in a lot of practices. It's gonna be hard to implement.

Steven E. Nissen 20:12

Yeah, there are two nuances here. One is that you have these percent risks, and these are based upon the pooled cohort equations. And many of us believe them to be largely flawed, not very accurate. They've been studied, not very accurate, and they're they've become somewhat out of date, and they don't include some key uh aspects of risk. And the most important one they don't include is family history. Right. Yes, and so so here's the problem is so somebody gets a calculated risk of 10%, but they tell you that everybody in their family's had an MI, a stroke, or bypass surgery in their 40s and they're in their mid-40s. You know, you can't look them in the eye and say, well, your 10-year risk is 10%. And you know, that's the problem. And I think the risk calculator needs to be redone. Nobody seems to have the stomach for doing it. I prefer the Reynolds risk score, which I use uh preferably over a pool cohort equations because it's proven to perform better and includes both family history and the level of C reactive protein, which we tend to get in a lot of our patients.

Lori Dickerson 21:30

It's a great point. And we have uh written about the Reynolds risk score, and I believe it is in our um in our clinical resource chart again is another option. And you know, Stephen, I wanted to call on you as a primary care doc, you know, um when you're looking at these patients and applying shared decision making, considering cardiovascular risk and LDL targets, um how are you approaching this and how are you teaching about this in your practice?

Stephen Carek 21:57

Yeah, that's a really great question. And how we individual individual Decision. It involves a lot of nuance, it feels. I agree with the sort of general theme of it's better to be lower, but how you get there is vital. So many patients that we have, you know, another pill is another burden to them in a multitude of ways, whether cost or access or side effects. But and asking their engagement of what they envision themselves getting to these lower LDL calls, whether that's when they prioritize. Is it through a statin? Is it through radical dietary changes, whether they want to adhere to more of a plant-based diet or a Mediterranean diet, whether they want to engage in more physical activity, whether they want to sort of cut back on alcohol or all these other sort of lifestyle-related, modifiable risk factors for cardiovascular disease, let the patient kind of dictate where they want to go first. And if we can motivate them to do some of these lifestyle changes, that really is a great starting point for them. Again, but if they're super high risk in these high-risk area, they tend to want to sort of have a more serious conversation that medicines may be a little bit better in addition to these good lifestyle changes.

Lori Dickerson 23:01

Okay, great perspective. And I want to move us along in our article here to get to some of our treatment options. We do, of course, encourage evaluating adherence to lifestyle changes and the statin to address and to address any statin concerns. And we have some examples here also, such as other ways to encourage statin use, like taking a statin holiday or getting a buy-in before restarting a statin and considering a different statin. We've written about some strategies for getting folks to stick with a statin. But Steve, let's come back to when should a non-statin should be considered. And of course, uh, we are talking about uh especially those patients at very high risk, um, and looking at the the non-statin LDL-lowering medications, such as azetamide or PCSK9s or bempadoic acid. So, which non-statin would you consider first in these patients, Steve?

Steven E. Nissen 23:53

I almost always try azetamide first. First of all, it is very inexpensive. I has very low uh uh adverse effect profile. Its effect is modest, but it it, if you think about it, it's equivalent to giving a lot more statin. There's something a little nuanced here that we frequently do. We have people that seem to be sensitive to higher doses of statin. So we try to titrate up their resuvastatin and we start to get to higher levels, and and they have you know muscle-related or other adverse effects. Well, five milligrams of resubastatin plus azetamide is equivalent to 40 milligrams of resubastatin without azetamide. And so think of acetamide as kind of an amplifier of the efficacy that's worth doing. However, there are people on top dose of resuvastatin, that's the most effective statin. You get 20%. It is 10 bucks a month, it's about right. And uh it's certainly safe. Uh, its effect on cardiovascular morbidity mortality. They did a very poor trial, the improvit trial, but uh nonetheless, it did achieve an end point, albeit with a pretty small relative risk reduction.

Lori Dickerson 25:16

And uh I think we've also discussed the PCSK9s, just to add on to that, Steve, and considering those, they do reduce cardiovascular events and some high-risk patients also on a statin uh lower LDL another 50% or so, but they do cost about $550 a month. And so that um is coming down, but still a barrier for for many patients. So um glad you agree with our recommendation to leading towards adding a Zetamib first. And Andy, I wanted to hear from you too. You're seeing these folks in the hospital who maybe have had a secondary event or onostatin. And so are you are you going ahead and adding a second agent, or is this something that's mostly being done as an out uh with your outpatient colleagues?

Anthony A. Donato 25:58

Yeah, Lori, um uh I'm gonna be a bit of a nihilist about this. Um uh this is a chronic disease. When I see them in the hospital, as everyone on the call knows, uh uh cholesterol is an acute phase reactant that's negative, so it drops down. So I don't even know their true baseline. So uh this is please leave this for for Andrea and her colleagues to kind of manage because uh um I if you add on two, three drugs when they leave and this is one of them, someone is a side effect, they stop all of them. It's it's really it doesn't belong in my world.

Lori Dickerson 26:28

Very good. Appreciate that feedback. And um I just wanted to make sure that our viewers heard that perspective too from uh from from you, because I think sometimes folks might wonder why they didn't come out on a statin here, or why did they not come out on a second agent? And I think that's a great explanation for why those changes weren't made in-house.

Anthony A. Donato 26:46

To be clear, um if I've somebody's uh not on something and they come in with an event, I absolutely put them on statin, but I don't I don't double down.

Lori Dickerson 26:53

Sure, sure, sure, for sure. Yeah, great clarification. And then we also make the point um to avoid jumping to other non-statins uh that aren't shown to improve cardiovascular outcomes with an optimized statin. And so, Steve, I'm curious about your thoughts on this statement.

Steven E. Nissen 27:08

Well, the FDA has not acted on our, we did our course the clear outcome trial with uh bempadoic acid, and so it doesn't actually have a label yet, but I I suspect that it will. Um I we tend to reserve it for people that have difficulty uh tolerating a statin. There is one uh interesting nuance here. The combination of bempidoic acid and azetamide lowers LDL pretty close to 40 percent. That's about as much as most modern intensity statins. And so for someone who really can't take a statin, bempidoic acid plus a zetamide is a pretty good alternative. I wanted to make one more point. The choice of statin is pretty important, and um, I would advise people to stay away from symbostatin. Symbostatin has too many drug-drug interactions. You get into all kinds of trouble when you give, you know, amiodarone or amlodipine or some a lot of different things, and you get into problems with toxicity. And we have better statins, they're all the same price, so you might as well give one that doesn't have the drug-drug interactions.

Lori Dickerson 28:18

Great advice. And to close out this discussion, I want to uh talk about our last paragraph in our article, which is can LDL be too low? And we state don't back off just because LDL is very low. Long-term data with PCSK9 inhibitors link LDL under 40 with lower cardiovascular risk without increasing safety concerns. And so wondering about your thoughts, Steve, on the practicality of this statement.

Steven E. Nissen 28:41

So, what I to what I teach people is that LDL is too low if it goes below zero. I mean, seriously, that we've never been able to show any any adverse effects of very, very low LDLs. In some of the trials that I've done, we've had LDLs in the single digits with no difficulties. And um, you know, I don't think it's a problem. Now, you don't have to take it down to a level of 10. The lowest we've achieved in a trial I've done was the uh Glagov trial. We got to a median LDL of 36, and we saw benefits on disease progression. That means half the people were under a level of 36. So, and there was no safety issues with getting that low. The other comment you had a slide up just a minute ago, which included enclyceran. Yes, we are using more enclysteran uh for a number of reasons, not the least of which is that the adherence issue is really taken care of. You know, they come in the clinic for an appointment twice a year, then your your nurse gives them an injection, they're good to go for six months. If they don't show up for clinic, then you can have concerns about adherence and you can contact them and try to get them back in compliance. You know, with a lot of agents, you really don't know if they're getting the drug or not. With enclyscuran, you do because it's given under direct observation.

Lori Dickerson 30:07

Well, great conclusions there with respect to the non-statin add-ons that we can consider to statins uh when we're looking at blending our LDL targets uh and uh percent reductions. It's been a great discussion. We're out of time for this segment. I do want to refer everyone to our chart titled Cholesterol Guidelines. It's an FAQ that addresses your common questions, such as who should be assessed for cardiovascular risk and how. So I encourage everybody to check it out.

Narrator 30:37

We hope you enjoyed and gained practical insights from listening into this discussion. Now that you've listened, you can receive CE credit from Pharmacist Letter. Just log into your Pharmacist Letter account and look for the title of this podcast and the list of available CE courses. You'll also be able to access and print out additional materials on this topic, like charts and other quick reference tools from the Pharmacist Letter website. If you're not yet a Pharmacist Letter subscriber, find out more about our product offerings at TRCHealthcare.com. Be sure to follow or subscribe, rate, and review this show in your favorite podcast app. It helps spread the word about our show and is a great way for you to let us know how we're doing. You can also reach out to provide feedback or make suggestions by emailing us at contact us at trchealthcare.com. Thanks for listening to Medication Talk.