Difficult-to-treat hypercholesterolemia: case report

Abstract

Introduction: Dyslipidemia is one of the main risk factors of atherosclerosis, which is the main cause of death in developed countries, including Portugal. Despite lifestyle changes and lipid-lowering therapy with statins and ezetimibe, many patients do not reach the recommended LDL-cholesterol (LDL-c) levels. PCSK9 inhibitors are a new therapeutic option, which allows a significant reduction of these values (50-60%).

Case description: Female, 66 years old, with a history of type 2 diabetes mellitus, arterial hypertension, dyslipidemia, and overweight. Many family members with dyslipidemia. For several years, she has presented values of total cholesterol, triglycerides, and LDL-c out of the target (LDL-c in the order of 230 mg/dL), despite optimized medical therapy. Due to the persistence of these values and family history, she was referred to a hospital consultation of Internal Medicine, for evaluation of the indication to start treatment with iPCSK9. She started treatment with evolocumab, having presented, after 4 weeks, LDL-c of 66 mg/dL (reduction of about 77%).

Comment: Although relatively recent, these new drugs have shown a further reduction in the risk of cardiovascular events, with a good safety profile. However, due to the high costs, its use in clinical practice should consider its cost-effectiveness. Priority should be given to its use in patients at higher cardiovascular risk and who maintain high LDL-c levels despite optimized lipid-lowering therapy. It is administered subcutaneously every two to four weeks, with steady-state trough serum concentrations being reached within twelve weeks. Semi-annual monitoring should be maintained. Currently, the prescription of these drugs is limited to secondary health care, but the role of the family doctor is fundamental to identifying and referring patients who may have the criteria to start this type of treatment.