Utility and Appropriate Use of PCSK9 Inhibitors in the Current Era

Abstract

Atherosclerotic cardiovascular diseases (ASCVD) remain the number one cause of death and morbidity in the country. Elevated cholesterol/hyperlipidemia has been considered one of the major risk factors for ASCVD. Statins have been the main stay therapy for treating hyperlipidemia achieving remarkable clinical benefits; however; its inability to achieve the desired reduction in the low density lipoprotein cholesterol (LDL) in some people and the disabling side effects from it in others, has led to a search for an alternative therapy. One of the groundbreaking inventions in this field has been the advent of the proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i). These agents have similar efficacy to high intensity statins and at the same time are tolerated well with a low incidence of side effects. Based on the results from multiple large scale clinical outcome trials, this class of LDL-C lowering agents has been recommended as appropriate second-line agents, or as an alternative therapy in cases of significant statin intolerance, for patients with established ASCVD and suboptimal LDL levels. As evidence supporting their efficacy and safety continues to mount, use of PCSK9i is likely to keep expanding in the current ASCVD population. In this chapter we discuss the advent of PCSK9i, their clinical utility, and their appropriate use keeping in view the high drug cost and other barriers in prescribing them.