CEimpact Podcast

Practical Updates From the New Cholesterol Guidelines

Share episode

Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.

0:00 | 41:12

Updated cholesterol guidelines introduce important changes in cardiovascular risk assessment and lipid management that directly impact pharmacist practice. This course reviews key updates from the new ACC/AHA dyslipidemia guideline, including risk assessment tools, LDL-C targets, and evolving roles for statin and nonstatin therapies. You will be better prepared to identify practice-relevant recommendations and support evidence-based lipid management in patient care.

HOST
Rachel Maynard, PharmD
GameChangers Podcast Host and Clinical Editor, CEimpact
Lead Editor, Pyrls

Janelle Ruisinger, PharmD, FAPhA
Associate Dean for Academic Affairs and Clinical Professor
The University of Kansas School of Pharmacy

GET CE FOR LISTENING!
Stay Compliant. Grow Clinically. Practice with Confidence. 

Pharmacist CE Subscription: All your CE in one convenient subscription.
All episodes, CE, and Practice Resources for the GameChangers Clinical Update is included with your Pharmacist CE Subscription. But wait…there’s even more!

The Pharmacist CE Subscription includes: 
-  Compliance and licensure CE 
-  GameChangers Clinical Updates 
-  Practical continuing education across patient care topics 

*The subscription does not include microcredentials or certificates, which are available separately for pharmacists seeking specialized service training. 

Purchase Now!



PRACTICE RESOURCE
Receive the exclusive Practice Resource to use as a reference guide for this episode by purchasing the Pharmacist CE Subscription.

 
CPE REDEMPTION
This course is accredited for continuing pharmacy education! Click the link below that applies to you to take the exam and evaluation to claim credit:

 

CPE INFORMATION

Learning Objectives

Upon successful completion of this knowledge-based activity, participants should be able to:

1. Describe key pharmacist-relevant updates in the new ACC/AHA Guideline for the Management of Dyslipidemia.

2. Differentiate risk assessment and lipid-lowering treatment considerations that may influence pharmacist recommendations under the updated guideline.


Rachel Maynard and Janelle Ruisinger have no relevant financial relationships to disclose.


0.75 CEU/0.75 Hr
UAN: 0107-0000-26-156-H01-P
Initial release date: 5/4/2026
Expiration date: 5/4/2027
Additional CPE details can be found here.

Follow CEimpact on Social Media:
LinkedIn
Instagram

CE Credit And Show Welcome

SPEAKER_01

Here on Game Changers, we're all about helping you stay ahead of pharmacy practice. But why stop at listening? You can earn CE credit for this episode and hundreds more by visiting CEimpact.com and logging into your account or creating a new one. Get credit, get inspired, and make your learning count. Hey CE Impact subscribers. Welcome to the Game Changers Clinical Update Podcast. I'm your host, Rachel Maynard. I'm super excited about our topic today. We're going to be talking about the new American College of Cardiology, American Heart Association guideline on the management of dyslipidemia. This is a big deal. The guideline retires and replaces the 2018 cholesterol guidelines. And there are a number of practice-changing updates that will impact how we care for patients with dyslipidemia. So we'll focus on those key changes, what the evidence shows, and what we as pharmacists should do differently in practice. And I am thrilled to share that we have a pharmacist expert who was on the peer review committee for these guidelines, Dr. Janelle Rusinger. So welcome, Janelle. We're so pleased to have your unique expertise for this topic.

SPEAKER_00

Hello, Rachel. Thank you for having me. I'm really happy to be here.

Meet The Guideline Peer Reviewer

SPEAKER_01

We really appreciate your time carving out of your busy schedule. And I know you've been on the podcast before, but for our listeners who maybe haven't heard from you before, if you could share a little bit about your background, your current role, and why you're interested in this topic outside of that peer review committee that I mentioned.

SPEAKER_00

Sure, sure. So I'm the Associate Dean for Academic Affairs at the University of Kansas School of Pharmacy. And I've been here for 26 years. So part of that role, I yeah, and I was a I'm a clinical professor as well. And so part of my role here at KU is to have a practice site. And so I was in the Atherosclerosis and Lipid Aphoresis Center at the University of Kansas Medical Center for probably about 20 to 24 years. That was a physician-run clinic, but there were two pharmacists in that clinic, and we got to practice under protocol with Dr. Patrick Moriarty. And since it was a specialty clinic, our patients were referred to us. So we saw the worst of the worst when it came to dyslipidemia, when it came to tolerating medications, when it came to family history and events and things like that. So that's where that passion comes from and still lives on.

SPEAKER_01

Absolutely. And definitely a unique patient population. So you've probably, as you said, seen some interesting cases that would help shape your understanding of this topic for sure.

SPEAKER_00

Definitely. Definitely. It was a lot of fun, challenging, but yes, a lot of fun.

What The 2018 Guidance Said

SPEAKER_01

Yeah. Yeah. Excellent. Well, let's just dive right in because I think we have a lot of ground to cover. And I do want to start with just getting us on the same page around the 2018 2018 guidelines. I mentioned those are being retired and replaced with this new set of guidelines. And think about where we were and then where we're going. So if you could give a brief overview of where we were, and then we'll get into where we're going with these new changes.

SPEAKER_00

Sure. So with the 2018 guidelines, we had thresholds instead of lipid goals. And so we were looking to lower the LDL 30% or 50%, depending on the risk. We were using moderate intensity, high intensity statins kind of based on how much we needed to lower that LDL. So that is one thing that'll be different that we can talk about here. The other thing is when we were using our risk calculator, the risk calculator was for those who were 40 to 75 years old. And our new risk calculator gets us down to patients who are 30, up all the way up to 79. So we broadened that age group as well. And then we also reduced the level where we consider risk. And so before it was 5% or higher, now it's 3% or higher. And so a few of the major changes there as well. We talk a little bit more about the non-statin therapies that are options for our patients and the strong data that's behind putting those with the statins are a few of the changes. You know, some things still stayed the same. The lifestyle modifications, right, are still key, regardless of whether you're on a medication or not. So some really great changes and then a few things that that stayed the same.

SPEAKER_01

Yeah. Yeah. Well, I won't keep us in suspense anymore. And we could get right into those changes. But I do remember when those 2018 guidelines came out and it was a big shift in thinking then because we had moved from LDL goals to using target statin doses. And that was a big change. And now we're sort of the pendulum is going back in the other direction. And as you alluded to. So let's go ahead and get right into those changes and let's start with maybe those LDL targets, as you mentioned, because I do think that's a pretty significant change.

SPEAKER_00

Sure. Absolutely. So we come back to our LDL targets. And so for our patients who are considered very high risk, their LDL target now is less than 55 milligrams per deciliter. So we did not even see that before, right? When we had our targets, it was less than 70, but we know now that lower is better. And so they brought the the level down a little bit. Now, and that follows the European guidelines, because the European Guidelines has had their their for their high-risk patients, the LDL less than 55 for a number of years now. And so that is one of the one of the big changes, but it's also exciting. And then the other one, we still have our LDL goal less than 70 and less than 100 for those other patients based on their risk stratification.

SPEAKER_01

So just to clarify, the LDL less than 55 is for those secondary prevention patients. So patients who have had a heart attack or stroke cardiovascular event, who are in that high highest risk category is the less than 55 target for them. Can you speak a little bit more about when the less than 100, less than 70 cutoff applies?

SPEAKER_00

Sure, sure. So a couple of places where that is going to come into play is if you're looking at calcium scoring. And so they stratify that based on that particular score. And then also when you're looking at doing that prevent calculation and how they're, if they're coming out as low risk, moderate risk, high risk based on their percentage, are a couple of areas where those will come into play.

Prevent Risk Calculator And Who Qualifies

SPEAKER_01

Okay. So let's go, let's back up a step, I think. And and you mentioned the prevent cardiovascular risk calculator, because I that that's a change too. And so let's talk about that a little bit more, how that compares to what we were using and why that's now the recommended calculator and key considerations with using it. Sure, sure.

SPEAKER_00

And so before we did have the ACC AHA um risk calculator, and again, it was from age 40 to 79, but we know that patients younger than that can have events and can be at risk. And so this new prevent calculator actually will assess risk from 30, like I mentioned earlier, all the way up to age 79. And why that's important is because we know that cardiovascular disease, ASCVD doesn't develop overnight, right? It's a long process, but it and it's related to exposure to the LDL, right? Exposure over time, LDL and other parts of the cholesterol. So if we can get that lower sooner, we are going to prevent the patients, hopefully prevent events over time. And so being more aggressive sooner is kind of where that prevent calculator is fitting in opposed to our previous calculator. And then again, as we mentioned, we're now looking at 3% and higher risk opposed to the 5% and higher risk. And again, that's because you want to reduce that exposure sooner to hopefully prevent events down the road.

SPEAKER_01

Would you fair to say that, would it be fair to say that the general takeaway or sort of message from the guidelines is lower is better for longer. Like over the course of your life, lower is better. And that's why, as you say, there's this focus or attention ability to identify patients as young as 30 with the risk calculator and treating at lower thresholds, treating to lower targets. Is that a fair sort of summary?

SPEAKER_00

Yes, that's a great summary.

unknown

Yep.

SPEAKER_01

Okay.

SPEAKER_00

Lower longer is what we're essentially looking for. And again, that's simply to reduce those events down the road. Five, 10, 50, you know, people are living longer, you know, and so we want to reduce those events over time.

SPEAKER_01

And what about the the data, the evidence to support some of these changes? Has there been new sort of obviously it's been 10-ish, eight to 10 years since the last guidelines were published? So what evidence has been has come out since then that has led to that lower is better for longer?

SPEAKER_00

Sure, sure. Some of it I think is when you're looking at some of these new therapies that have come out in the past few years. So for example, the PCSK9 inhibitors, I know they were out with the, you know, other guidelines, but you know, there's a lot of data out there now with some of these add-on therapies on how well the patients are doing with that very low LDL. And so, yes, and that's another thing that I love about these guidelines is they're, you know, they are evidence-based and are, and they have been in the past, but we've got the strong evidence to support those recommendations that yes, the lower we get that cholesterol, the better outcomes we tend to have with the patients.

SPEAKER_01

Yeah. And I'm glad you brought up the PCSK9 inhibitors because that's, I think, where we've seen this pretty dramatic lowering of LDL in some cases. And so it makes sense, right? That once we're seeing that data with especially longer-term data with those drugs, we are able to see this lower is better. And also that there's less concern about going too low. Like I think that was a concern in the past, is how low is too low? Is that something we need to be concerned about? But again, with these PCS canine inhibitors like alerochumab and evaluationab, we have more data that's maybe reassuring about that too.

SPEAKER_00

Maybe you can speak to that a little bit. Definitely. Definitely. And so, right, there were there were concerns that you know you could go too low and and cause problems. And we have not seen that in the can, you know, randomized controlled trials that are out there. And then we have a lot of data from patients now that they're out there, right? The drugs are out there and they've been used for quite a while. We aren't seeing this surge in in events from related to cholesterol that's too low.

SPEAKER_01

Mm-hmm. And seeing benefit on the other hand, absolutely benefit. And that's driving some of these changes that we're seeing in the guidelines. Okay. Okay. That's good clarification. And so going back to that prevent calculator, and there are a couple of prevent calculators. So for people who are pharmacists who are going in and using this maybe for the first time, can you speak a little bit more about which calculator we're using? What are the variables that go into it? What you do with the results? How does that look if you were actually wanting to use this in practice?

SPEAKER_00

Sure. You know, and kind of and that's a good point too. You know, using it in practice, it requires a couple of lipid levels, right? It requires the systolic blood pressure and and their whether they have, you know, diabetes and smoking and hypertension and things like that. Uh, and so a pharmacist, if you're thinking about being in that community setting or even in a busy clinic, you could certainly use a technician to input that information. And then the pharmacist can be the one to have that discussion with the patient and that clinical decision making. And so I I I want to touch on that just a little bit because I know that for some pharmacists, you know, when you're in a busy pharmacy, you're thinking, how in the world am I going to have time to do all this? And so if you do have some of those, those readings, then you can certainly let, you know, some a pharmacy student could check the blood pressure and then also put that information into the into the into the calculator for for sure. And so I know the one that I went and used here not too long ago was just the one that was actually, I think there was a link to it in the guidelines or I Googled it and it there was the it came up to it. And so that's the one I used. And it's very, it feels very similar to the other risk calculator in in the way it looks and then the information that you're putting in and things like that. But then again, it's talks a little bit about that less than or that higher than three percent and and does the risk stratification from that point. And then again, um, you in the old one, if you would put in someone who was less than 40, it wouldn't give you the information. And you know, now when I was playing around with it, I you know, you put in someone who's 30, who's 31, 35, adjust the numbers a little bit, kind of see how that would impact if if you're just wanting to be familiar with it and and what the results might look like. That's that's some some pieces of that one that that are going to be a little bit different.

SPEAKER_01

Yeah. So I love a couple of points that you brought up there that it's accessible, it's easy to use. So like you say, prevent risk calculator. And there's the prevent CBD risk calculator, which we talked about actually on a prior podcast, which is in the hypertension guidelines, and using that in terms of assessing hypertensive risk, and then prevent ASCBD, which is the one in these guidelines. And then I think there's also prevent heart failure calculator too. So you just have to look at that when you're selecting, making sure you're selecting the right guideline in terms of discussing these risks with patients. But like you say, it's very easy. And I did it for myself, you know, just to play with it and see how it looks and what results you get. And you get the 10-year and 30-year cardiovascular risk, and that's what you use, as you said, to help then take the next step around, okay, is it low less than 3% or borderline 3% to 5% or higher, and then make your treatment decisions from there. So I'd encourage our listeners to just play with it themselves and see, you know, how it how it looks. And then, as you say, have a technician, have an intern use that and they can sort of pull it up, get it ready, and you have that and that cardiovascular risk percent uh for the discussion with the patient. Great point. And so once we once we have those results, what is your sort of next step in terms of decision making and what would you talk to a patient about? And actually, just to clarify too, that calculator is for primary prevention. So again, we're not talking about patients who've had a cardiovascular event, we're talking about those who have not and assessing whether they need a standard or other lipid lowering therapy.

Statin Hesitation Myths And Counseling

SPEAKER_00

Right. Right. Yeah. And so you, you know, if it's if it's less than three percent, you talk to them about maintaining a healthy lifestyle and kind of, you know, keeping an eye on it and and plugging along. You know, if it's that three to five percent, you're kind of looking at some some other pieces that could could play in and and what other risk stratification can you do? You know, maybe it's time to to look at an APOB level or or maybe, you know, even a calcium score if if if there are some other things that would point to it. And then as they move up in the the risk stratification, then it is time to start talking about starting that statin therapy and and trying to get that LDL down again, along with the lifestyle modifications and and things like that. So I think where pharmacists may start getting some some questions and and play a really key role again is in some of those younger patients that are now going to either qualify for a statin or they're going to be on the border and helping them understand that, you know, less is more, and right. So you want it lower for longer, like we said earlier. And, you know, I recognize that nobody, nobody walks in and says, Man, I can't wait to start a new medication, right? That's not that's not what patients do. And and so having that conversation, addressing any concerns, addressing any misinformation, because man, they go, you know, they go on the internet and they can find all kinds of misinformation. And so, or even, you know, helping correct that, but also guiding them to useful, reputable websites that are patient-friendly. And so thinking about the American Heart Association and the great information they have there that, you know, there's the part that's for patients, there's the part that's for healthcare professionals, and and pointing them to some of those reputable, reputable sites, or even having handouts at the pharmacy if you have a population that, you know, a lot of people that that may qualify that for for therapy or or to be addressing those issues to help guide them and and point them in a direction where they can get some some strong, reputable, good information.

SPEAKER_01

That is so challenging. And and like you say, because more people will qualify, I think a lot of the concerns that we've heard for years about statins in terms of muscle aches and even dementia, some of these concerns, diabetes, uh, all of these issues, I think are going to sort of crop up probably again in conversations. So, how would you help navigate those discussions for pharmacists who are talking with patients who really may benefit from a statin for the reasons you said and and are now qualifying for a statin? How, how do you have those discussions? Sure, sure.

SPEAKER_00

Um you, yeah, and it's gonna take multiple discussions, right? There isn't going to be one answer that's, you know, all of a sudden they're gonna, you know, agree to it. They're gonna be hesitant and and have their beliefs. And so you just have to kind of keep at it. But, you know, letting patients know that the the percent of patients that get the muscle aches and pains from statins is is pretty low. And if they do get it, you can always reduce the dose. We can try a different statin, we can do alternative dosing, you know, they can stop it and then see if the muscle aches improve. Because the other thing we see, right, when someone learns that their cholesterol is high, they tend to maybe start an exercise regimen or right. And so if you're doing that at the same time, then you may blame the muscle aches and pains on the statin, whereas in fact, it's because you know, you haven't really exercised much for for a long time. The diabetes one came up a lot in our clinic, you know, early on. It seems to have kind of faded a little bit, but again, patients who don't want to take a statin will kind of latch on to that. And and certainly letting them know that the benefit of a statin outweighs the risk of of the diabetes. And it's it's not, we usually see those blood sugars go up a little bit in patients who already have risk factors for diabetes. It's not someone who, you know, it's usually those that have their blood sugars a little bit high already or already have that, you know, metabolic syndrome going on and and things like that. And again, the benefits of that satin will outweigh the the risk of of that for sure.

Hitting Goals With Add On Therapy

SPEAKER_01

And to tack onto that concept too, I'm glad you called out some of those other risk factors. And there are, I think, considerations in the guideline around some of these other risk-enhancing factors. So even outside of the what you plug into the calculator, like metabolic syndrome, I think is one of them, other risk-enhancing factors that might contribute to a person's overall cardiovascular risk. But with diabetes specifically, the guidelines do reiterate the importance of a statin for patients with diabetes, that is a population that is indicated to receive statins, right? Absolutely. Yep. So so even if it if there's concern about that, as you said, it's patients who may have already been at risk anyway, maybe it tip them over the threshold. And even so, if you have diabetes, a statin is indicated. So good reminder and discussion point there too. So we've talked a lot about statins. Let's thinking about what in since the prior goal was knowing you'd have to use a high or moderate intensity statin for certain patients. How does that come into play now with these LDL goals? And and again, I know it depends on the patient-specific risk that we're talking about, but where do high and moderate intensity statins sort of fit in here?

SPEAKER_00

Sure, sure. So let's kind of think about that getting a lot of our patients to less than 55 or less than 70. We can kind of start there. You know, even a high intensity statin. So when you're thinking of your top dose of Versuvastatin, your top dose of a torvostatin, you're probably not going to get everyone down to less than 55. And so we're probably going to need add-on therapy, whether that's a zetomib, whether that's a PCSK9 inhibitor, right? Maybe both. We had patients in our clinic that were actually on all three. But also thinking about the the highest tolerated dose of statin. There's some talk in the guidelines about that as well, right? And so if a patient starts resubostatin 40, gets the muscle aches and pains, really struggling with it, maybe back them down to 20. May, you know, it's going to pull them back from their goal a little bit. But we have a whole arsenal of other medications that we can add on to get them down to that goal. And sometimes that takes a little bit of convincing and discussion as well. But hopefully the patient, we can motivate the patient to want to get their cholesterol down. And then, you know, any more, the the statins we can do, a statin that they can take any time of the day, right? The high intensity ones, we can certainly do that. Azetomib, you can take any time of the day. Um, the PCS gain inhibitors are not a daily dosing, you know, even though it's an injection. So I think we are also coming out as you add on medications, regimens that are still manageable for the patients to get that LDL down to where it, to where it needs to be. If you're thinking of a goal of less than 100, you know, hopefully we can do that with a high intensity statin. But again, if they can't tolerate it, we may need to add a medication or and it all depends on where they're starting, what their starting level is also.

SPEAKER_01

Right, of course.

SPEAKER_00

I was gonna say, and I think something else really important where pharmacists can um have a huge impact is for the adherence of these medications. Um you don't feel any different whether your cholesterol is high or low a lot of times. And in fact, you may, in your mind, feel a little bit worse if you're on a statin, whether that's real or or perceived. And pharmacists are gonna be huge in following up and asking the patient, you know, looks like you're you're needing a refill on your statin. How are you doing on that? And and talking to them about it. Because it's astonishing the number of patients who receive prescriptions but don't fill them, or they'll fill them and then never take them and never get a refill. So that's another huge place where pharmacists can can make a big impact.

SPEAKER_01

Absolutely. So so many great points there. The idea of adherence and not only the adherence once a patient starts and maybe they get their first month and then they have some issues and whether whatever the issue might be, it's worth uh if they're Not getting that refill, evaluating, having that open discussion, having the safe space for them to feel like they can share any concerns that they might be having and working through that. Because as you said, there's a whole menu of options available. There's alternative statins that you can try. There's lowering the dose options. So there's lots of different ways that we can work together to help them get to a lipid lowering regimen that will work for them. But also that primary non-adherence issue where a patient who doesn't come in for the prescription in the first place and before returning those back to stock, perhaps recognizing, oh, this is a new statin for this patient. As you said, a lot more people are going to qualify. So these might be patients who maybe there was something lost in communication with their provider and maybe following up to say, hey, did you know you had this statin? You never picked it up. Just wanted to talk through what you and your physician talked about. So yeah, I think that's a really important point to bring up. And just again, staying alert for some of those gaps and also then working with the patient to talk through any concerns they have and helping them stay adherent with it. Uh and again, going back to the menu of options with the statins, and then as you said, azetomide the PCS canine inhibitors, and helping patients understand that even though the goals are lower than they were before, there are more options to get you help get you to those targets. So it's not out of reach, it's just something we might need to work through. One class or one drug that's relatively newer is Bempadoic acid. And I think that one is less familiar maybe to some of us because it's it's newer. And so could you talk a little bit about the role of that drug specifically, just how it fits in compared to Zetamive and the PCSK9s?

SPEAKER_00

Sure, sure. It's a stepwise approach, right? And so you kind of have to just find the right cocktail for the right patient. And as much as you, you know, we just have to also acknowledge that insurance may have play a role in that, also, right? And so I think the nice step a lot of times can be a statin and a zetomide because it's they're both generic. And so hopefully affordable, easy, accessible. You get in in the PCSK9 inhibitors, not generic can be quite expensive. And then the same with bempadoic acid, not generic can be quite expensive. The other thing to think about is where you are. So after you hit the statin and the acetomide, you know, do I need another 30, 40 percent? You may need to hit a PCS-K9 inhibitor opposed to bempadoic acid, which isn't going to give you quite as much as that. I mean, it'll give you uh some, but you're not gonna get the the bang that you are like you will with the PCSK9 inhibitors. And then the other thing for a practitioner and a pharmacist, if a patient is just like, I cannot give myself the injection, I don't have anyone that can do it, I'm terrified of needles, I'm not doing that, then that's kind of answered there for us, right? And and maybe Bempidoic acid is a better approach than the PCS-K9 inhibitor. And we can we can breach that with the or you know, go that way with the patient if we need to, if we still can't get them to goal on that, you know, triple therapy. So, like the physician used to say in our clinic, it's just a matter of finding the right cocktail for each individual patient. And sometimes it's hard to get the patients to stay patient with us because you don't want to throw it all on at the same time, right? And and that's gonna be even, I think, a little bit more of a challenge with these guidelines and these lower LDL goals for some of the patients because you want to do it in a stepwise approach. Um, you want to make sure they tolerate the medications before you add something else on. And so it'll it'll take a little bit, but we will be able to get there if if they'll stay with us for sure.

Older Drugs And Supplements Get Reframed

SPEAKER_01

Yeah, yeah. And thank you for providing that context. Cause as you say, there's a lot of it's it's nice to have options because, as you say, cost considerations can be an issue, injection versus oral, the LDL lowering you're looking for, patient-specific considerations like comorbidities, there's all sorts of those factors that come into play. So yeah, very nice to have options and good reminder that wouldn't lead to tailor depending on all of those factors for the patient. You know, those non-statins that sort of fell out of favor with the last guidelines, but what about things like fibrates or bioacid sequester and some of those older drugs? Like if we're thinking about cost, what is the role of some of those other agents?

SPEAKER_00

Sure, sure. I'm glad you brought that up because I did want to mention that it's interesting in these guidelines, or not interesting, but I think very appropriate in these guidelines. Gym Fibrazil is absolutely not recommended with a statin. It's contraindicated. So that's another place where pharmacists can really make an impact. And I, you know, occasionally you still see Gym Fibrazil or we did patients coming in clinic, and that was one of the first things we did was, you know, switch that over. And so something where pharmacists can be definitely screening for that if someone is starting a statin. Um, the the fibric acid derivatives, the fibrates, we're we're looking at phenofibrate, if they have really high triglycerides, again, the statins are still first line for for those patients, even in high triglycerides. If we're at triglycerides above a thousand, then we're worried about pancreatitis and need to kind of look at at the fibrates, at the prescription fish oil and and things like that to help bring that down. Um, and so that that's where those are. When you're thinking about, they do mention the bile acid sequestrants in in the guidelines. They're just challenging. You have to separate them from the other medications, right? Because they can they can bind if you are using the powder. It's like drinking sand, you know, and some patients don't like that. The pills, if you're taking the pills, they're very large and it can be difficult. And then the amount of LDL lowering that you get a lot of times isn't maybe what it can be with with some of the other agents, or it simply isn't what it is with some of the other agents. So it often feels like a lot of effort for not, you know, a lot. So then you think about I can take this teeny tiny azetamib opposed to drinking this powder, you know, niacin completely out of favor, does not have a place in lipid lowering. And then along with that, I'm just going to touch real quick on the supplements because the guidelines specifically call out supplements and say they aren't are not to be used for lipid lowering. So another great place where pharmacists can kind of catch that if someone's looking at the red yeast rice, if they're looking at the supplement fish oil section, if they're looking at ginger, cinnamon, you know, all of those that people read about or hear about on the internet or on TV or or whatever it is, those are not to be to be used. Um, and we're sticking with the prescription products that have the strong data behind them, the man good manufacturing practices, right? The regulations and and things like that.

Lp(a) ApoB And Calcium Scoring

SPEAKER_01

So yep, yep, have been studied and found to be effective and safe versus not necessarily knowing what you're getting in a supplement product and also not introducing potentially unknown drug interactions or other issues with if if somebody is taking this over the counter, they there's all sorts of issues that crop up. So I'm glad that you you brought that up. And something that absolutely pharmacists can be screening for, asking about as part of updating profiles or doing med reviews and evaluating that and helping to steer patients towards those proven therapies instead. Absolutely. And again, knowing that we have the options now to support LDL lowering in an effective and safe way, that it's a great way for us to redirect there. Um you mentioned fish oil for triglycerides, and uh glad you touched on the triglycerides because that is always a sort of conundrum too for patients with high triglycerides, but maybe maybe the LDL isn't concerned. And and as you say, reinforcing statins are still the first line for that as well, along with lifestyle changes too. So again, statins are are your go-to there as well. Yep, they certainly are. Okay, okay, great. So thinking about you mentioned a couple of those other markers like APOB and lipoprotein A. And so maybe you could speak a little bit more about those. I think those are maybe less familiar to us as pharmacists. And I know they're a pretty significant focus of the changes with the guidelines. So could you speak a little bit about some of those updates?

SPEAKER_00

Yeah, that is another thing that I'm really excited about, these guidelines, and something, again, that has been in the European guidelines for a number of years. But lipoprotein A is another component of the cholesterol. It can cause, you know, cardiovascular disease similar to LDL. But the interesting thing about that, about that particular molecule is that it's it's hereditary, it's inherited. So the level that you have is what you're going to have for life. And so some patients have very high levels. When you we would in our clinic, we would look at it in patients who had had events when they were young, if there was a family history, it got to a point where we pretty much screened, started screening it in everyone. And the guidelines now recommend for the first time a one one-time check for everyone. And so then, and then what do you do then if it's high? You then are more aggressive with the LDL lowering. Because the the catch with that is at this time, there aren't any agents that lower lipoprotein A a lot. The PCSK9s can lower it about 25%, kind of depends. But we so we can get a little bit of lowering there, but but there isn't anything that targets the lipoprotein A. But fingers crossed for the next set of guidelines because we've got some things in the pipeline that we're really excited about. Okay. But again, having that knowledge that I'm going to be aggressive with my other risk factors, my other, you know, components of my cholesterol, so that I can kind of mitigate any issue that that lipoprotein A may cause. Um, so that one's really exciting. The other one that you had mentioned is the ABO lipoprotein B. So this is another component of the cholesterol, again, very athrogenic. And it um is more, I saw it described the other day, kind of in a cool way. So it said if you think of a freeway, LDL are the people and the APOB are the cars. And if you reduce the number of people for car per car, but you still have all the cars on the freeway, it doesn't reduce the congestion, right? Yeah. Kind of an interesting way to think about it. And so for a patient who may have got their got to their LDL goal, but maybe they're still having events, you could look at that Apo lipoprotein B. And then that would tell us, okay, we need to be even more aggressive with that LDL. Or for patients with that metabolic syndrome, with diabetes, high triglycerides, those are some of our patients that would be good candidates for checking that abolipoprotein B. Also, in some patients who maybe who do not have events, do not have diabetes, but you did that prevent risk calculator, and maybe it's kind of unsure whether they should start a statin, checking that APO B is going to maybe give us more information where we could go one way or the other on that. So pharmacists may see more of those results coming in if they do have patients that bring in their lipid results, or they may start getting some questions about those particular products or why I'm, you know, my statin is being increased, or I'm, you know, getting another product added on. It may be because their lipoprotein A or their APOB is elevated. So that's a really exciting piece of the statins because you're looking at dyslipidemia as a whole and not simply hypercholesterolemia, which is a nice touch and I think is gonna help us even capture more patients and hopefully continue to reduce events.

SPEAKER_01

Yeah. And I I did not realize lipoprotein A is a one, one, you're born with it. It sounds like you have one, you're reading, and that's why the one-time check of it is sufficient for a lifetime and you get that really valuable information. So that does seem like a pretty significant change and something that more patients will be getting that data and and helping that shape their their risk assessment. And then the APOB, as you said, also another sort of risk enhancer that can help to guide that. You know, the other thing was the coronary artery of calcium. You mentioned that earlier too. Let let us know what where does that fit into and what does that suggest?

SPEAKER_00

Sure, sure. And so when you're thinking again about identifying risk, so someone who's already had an event, probably not gonna do it, right? Someone diabetes, probably not gonna do it. You've got they're already considered on that high risk. So it's those where you're just we're just unsure, right? Yeah, they might, or maybe they're given some pushback, they don't really want to start it. If it's a younger patient, doing a calcium score is gonna give you some nice information and help further assess their risk. And then again, based on what that score is, then you stratify their LDL goal and and how much we need to get that down. So something that we may be seeing a little bit more frequently as well.

SPEAKER_01

Yeah. Yeah. Yeah. So I again I think it's great that you mentioned these because as you say, patients may be having some of these values available to them and asking, what does this mean? How does it change the recommendation around what I should be taking? Do I need a statin? And if you have some of that data, that is a really powerful tool, I think, to help you with some of those discussions.

SPEAKER_00

Definitely. The the arsenal of things that we have to not only assess our patients and and kind of figure out where they need to be, and then the tools that we've got to help them get to their goals is just so exciting and has expanded so much even since the you know 2018 guidelines. It's yeah, it's really nice.

SPEAKER_01

And that's why it makes sense that we have this lower for longer is better and that you can you can reach that again with some of the the data and the tools that we have, as you say it. So that's great. So thinking about these updated guidelines, you know, if a pharmacist just sort of needs to be thinking about what do I need to, what what is going to be the question I'm gonna get tomorrow or what do I need to be most prepared about? Or so is there anything else that we've missed that you want to be sure we address in terms of these changes or what patients might be asking about?

How To Use A 90 Page Guideline

SPEAKER_00

Um I one thing I will say is if you if if someone decides to pull up the guidelines, they're 90 plus pages. And so honestly, right, we're not going to let's you know be realistic here. And but there is a nice, you know, at the beginning, and there's multiple places where are there, you know, the top takeaways from the new guidelines. And so being familiar with that, I think will maybe will help a lot of answer a lot of the questions. And if there's something in those top 10 where you're like, I'm not quite sure what that means, or or I need to learn a little bit more about that, then you can dig into that section of those guidelines. But I I I get concerned because I I fear that people are gonna open up those guidelines and see how many pages they are and just you know put it to the side and I'll I'll I'll worry about that later. But I think there are some things out there. There have been some nice, I've even seen a couple of nice YouTube videos that were only about five minutes, you know, that that this CE like this can certainly help. But but look at those key takeaways. And then there have been some documents that compare the old, the 2018 to the 2026. A couple of those are pretty long too, but just glancing through those to see some of the differences could be helpful as well.

SPEAKER_01

Yeah, I'm really glad you brought that up because it is it is a long set of guidelines. But like you say, there's the it's even called, I think, the top take-home messages, top 10 take-home messages. So you if you just want the cheat sheet, that's there. And then also I found the the algorithms and the flow charts and some of the graphics in the guidelines very helpful. So if you really just want a quick snapshot of okay, if a patient's prevent ASCBD score is this, this is what you do next. And it really does walk you through that patient care process, I think, really well. And also, I I saw a graphic about this this concept of through the lifetime. So screening younger patients too. So children and adolescents, I think, are part of the screening where they weren't before. Yeah. And then, you know, walking through and starting considering statins in the younger patients as well. So just some really nice graphics and algorithms to help make it more digestible too. So if you're, you know, just your control F or figure, you know, you can get through more quickly that way too. So I'm glad you brought that up as a don't get scared, just focus on if you need to just the bite-sized chunks get to it that way. Yeah.

SPEAKER_00

Greatness. And I will say that was very purposeful when in the review that was talked about a couple of times where we had to have those key takeaways for people. We wanted to make sure that the flow charts were easy to read and were not confusing. And and so that those will continue to be, you know, there's always it's always a work in progress. But that was a very mindful, intentional thing that they did for these. So again, hoping they're you they're not useful, right? If people aren't going to look at them or don't understand them. So we really wanted to make it user-friendly as much as we could.

The Game Changer And Wrap Up

SPEAKER_01

That's great. Inside scoop that you just shared, Janelle, from your peer review expertise there is sharing it, helping to make sure that the guidelines are usable and actually applied in practice. Because I I think that's the other thing is often it takes time to catch up with the guidelines. And so that, as you say, just get educating and making it easy to use. That's what we're all trying to go for here and get those messages out. So yeah, sounds like we've we've covered a lot of ground in terms of new the new risk calculator, the younger considerations and sort of that lifetime consideration of risk and how that leads to lower is better for longer. And, you know, as you talked about, the role of statins and non-statins and and clarifying that. So I just think there's a lot of opportunities for pharmacists to make patients aware of some of these changes, discuss the impact of these, help with adherence and really individualize care based on some of those factors you talked about. So yeah, great, great summary. And we covered a lot of ground. It is our game changers clinical update podcast. And so we always wrap up with what is the game changer? What do you think is the one thing that our listeners should walk away with from this guideline?

SPEAKER_00

Sure. We know from the evidence that, like you said, less for longer is the key to this. And we can't get our the LDL down, we can't get the cholesterol down unless the patients are taking the medications. And so I feel like the pharmacists are the real game changers in helping implement and get patients on board with the guidelines and and where they they need to be in in their therapy and in their their lipid levels.

SPEAKER_01

Yeah, yeah. Great, great bottom line there. I love it. And Janelle, I just want to thank you so much for your time and expertise on this. It it was really enlightening and as I say, a lot, a lot to learn, but little by little we'll incorporate in our practice and really make a positive difference to the patients' lives. So excellent. Thank you so much for your time. Thank you. I've I've really enjoyed it. Thank you for having me. Excellent. Well, listeners, I know we talked about a lot of great practical tips today, and these will all be summarized in the practice resource that goes along with this podcast on the CE Impact website. So I would just encourage you to check that out because it'll help take away some of the talking points that we had and really give you a tool that you could have by your side and practice. And be sure to claim your CE credit for this episode of Game Changers by logging in at ceimpact.com. And as always, have a great week and keep learning. I can't wait to dig into another game changing topic with you all next week.