Specialty · Clinical pathway

Traditional Hyperlipidemia Treatment without a Statin

A stepped non-statin medication sequence for patients who cannot take a statin or for whom a non-statin path is preferred after evaluation with Dr. Owens.

Shared foundation (2026 guideline)

The 2026 ACC/AHA/Multisociety Dyslipidemia Guideline (Circulation/JACC, 13 Mar 2026) replaced the 2018 guideline. Care here uses PREVENT-ASCVD risk estimation, a once-in-a-lifetime Lp(a), ApoB when it adds clarity, LDL goals matched to risk, screening for secondary causes, and lifestyle as the foundation. Lipids are typically rechecked 4–12 weeks after a change.

Who this is for

Patients with statin intolerance, contraindication, or a shared decision to pursue non-statin therapy after risk assessment. Medications are prescribed only after a visit.

Treatment sequence

1) Ezetimibe — usual first non-statin step for LDL lowering
2) Bempedoic acid — alone or as a fixed-dose combination with ezetimibe when additional LDL lowering is needed
3) PCSK9 monoclonal antibody (evolocumab or alirocumab) — injectable intensification when LDL remains above goal
4) Inclisiran — twice-yearly PCSK9-directed siRNA option when appropriate after discussion of logistics and cost

Triglycerides

Icosapent ethyl may be considered for selected patients with elevated triglycerides who meet indication criteria
Triglycerides ≥500 mg/dL — prioritize triglyceride-specific care and referral as needed; do not treat as an LDL-only problem

Cost and intensity

Out-of-pocket cost generally rises as therapy intensifies from oral agents to injectables. We discuss options, monitoring, and practical cost before escalating. No drug cash prices are listed on this page.

Expected path

Enroll → visit and safety review → start at the appropriate step → recheck lipids in 4–12 weeks → advance the sequence only if LDL (and related goals) remain unmet and the next step is appropriate.

Related hyperlipidemia pathways

Traditional Hyperlipidemia Treatment Rosuvastatin only — ACC/AHA intensity dosing with physician-supervised monitoring. Functional Health Hyperlipidemia Treatment without Traditional Medications Diet and lifestyle first — soluble fiber, plant sterols, berberine, and emerging bergamot; medications if goals are not met.

Educational information only — not personalized medical advice and not for emergencies. Call 911 for life-threatening situations. Prescriptions require a visit with Dr. Owens. Dietary supplements are not FDA-approved to diagnose, treat, cure, or prevent hyperlipidemia or any disease. Do not start, stop, or change a statin or other lipid medication without discussing it with your clinician.