Cholesterol management online: statins, PCSK9, ezetimibe
Lipid management is increasingly evidence-based and increasingly telehealth-friendly. Most patients are on a statin (or should be), the dose adjustments are routine, and the labs are easy to order. The decision-making is straightforward when you have a 10-year cardiovascular risk estimate in hand.
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Who needs treatment
ASCVD risk calculator (using age, sex, race, blood pressure, total/HDL cholesterol, diabetes, smoking) — 10-year risk > 7.5% generally warrants statin discussion. Existing cardiovascular disease, LDL > 190, or diabetes age 40-75 are automatic statin indications.
Statin selection
Atorvastatin 40-80mg or rosuvastatin 20-40mg for high-intensity therapy. Moderate-intensity for older patients or those who don't tolerate high-intensity. Pravastatin and pitavastatin have less drug-interaction risk. Generics cost $5-20/month.
Non-statin options
Ezetimibe (Zetia) — generic, adds ~20% LDL reduction. Bempedoic acid (Nexletol) for statin intolerance. PCSK9 inhibitors (Repatha, Praluent) — injectable, expensive, very effective for refractory cases. Telehealth handles prescribing; insurance approval is the friction.
Side effects and monitoring
Muscle aches in 5-10% — often manageable with dose adjustment or switching statin. CK and liver-function monitoring only if symptoms warrant — routine quarterly labs are obsolete. Repeat lipid panel 6-12 weeks after starting or changing dose.