In an interview with Pharmacy Times®, Amanda Gronniger, PharmD, CPh, BCCP, pharmacy clinical ambulatory specialist at Baptist Health South Florida, shared insights on pharmacist-led strategies to manage hyperlipidemia. Gronniger emphasized the importance of personalized lifestyle counseling, including achievable diet and exercise modifications tailored to each patient’s preferences and goals.
Gronniger highlighted pharmacists’ collaborative role in optimizing lipid-lowering therapy, particularly in complex or high-risk populations such as patients with diabetes or chronic kidney disease (CKD). She also addressed common challenges with statin adherence, offering tips to overcome patient hesitancy through education and individualized adjustments.
Pharmacy Times: What counseling tips do you find most effective when discussing lifestyle modifications with patients who have elevated cholesterol?
Amanda Gronniger, PharmD, CPh, BCCP: All patients should try to implement a healthy lifestyle for overall heart health. This includes targeting at least 150 minutes of moderate-intensity aerobic exercise or at least 75 minutes of vigorous-intensity aerobic exercise per week, preferably spread throughout the week. Moderate-intensity exercise can include brisk walking and water aerobics. Vigorous-intensity exercise can include running, swimming laps, and cycling uphill. Additionally, patients should target resistance training, ideally with 2 to 3 sessions per week. The best recommendation is for patients to find exercise that they enjoy and can maintain.
When it comes to diet, patients should try to emphasize intake of vegetables, fruits, whole grains, legumes, and healthy protein sources, such as low-fat dairy, low-fat poultry, fish, seafood, and nuts. It is recommended to limit intake of sweets, sugar-sweetened vegetables, red meat, and saturated fat. Fiber is another important dietary component that patients often overlook. According to the National Lipid Association, 5 to 10 g of daily soluble fiber can help decrease low-density lipoprotein (LDL) by 5 to 11 mg/dL. Just like with exercise, there is not a one-size-fits-all approach to diet—patients should focus on finding a dietary pattern that they can realistically maintain over time.
Although lifestyle modifications are essential, some patients may still require lipid-lowering medications. While triglycerides are greatly impacted by diet and exercise, LDL may only be decreased by 5% to 15% with lifestyle modifications alone. For high-risk patients or those with LDL of 190 mg/dL or greater, lifestyle modifications will likely not be enough. Rather than focusing solely on numbers, our goal is to reduce patients’ cardiovascular risk, often requiring medications that have been proven to reduce major adverse cardiovascular events (MACE).
Key Takeaways
1. Lifestyle counseling should be personalized to encourage sustainable changes in diet, exercise, and fiber intake, with realistic goals that support long-term cardiovascular health.
2. Pharmacists play a crucial role in optimizing therapy through collaborative practice agreements, managing adverse effects, and navigating prior authorizations, especially in high-risk or complex cases.
3. Emerging therapies like oral PCSK9 inhibitors and gene editing show promise in significantly lowering LDL and lipoprotein(a), offering hope for patients with limited options or injection aversions.
Pharmacy Times: How can pharmacists effectively collaborate with prescribers to optimize lipid-lowering therapy, especially in complex cases?
Gronniger: Pharmacists can play a key role in helping to optimize hyperlipidemia management. I currently work in a lipid clinic at Baptist Health South Florida and work closely with the providers and team by providing education to the patients, coordinating prior authorizations and appeals, and helping to manage adverse reactions. We have a team of reimbursement specialists embedded in our specialty pharmacy that works on all PCSK9 inhibitor prior authorizations and patient assistance programs for our hospital system. With the support of a collaborative practice agreement (CPA), I can adjust lipid-lowering therapies, such as modifying doses or selecting alternative medications, when patients are unable to tolerate a medication or require a dose adjustment.
Pharmacy Times: How should pharmacists approach cholesterol management in special populations, such as patients with diabetes or chronic kidney disease?
Gronniger: Patients with diabetes and/or chronic kidney disease (CKD) are at an increased risk of cardiovascular disease. For these patients, they may require more education when it comes to medications and why we recommend them. For example, guidelines recommend that all patients with diabetes aged 40 to 75 years should be on at least a moderate-intensity statin, regardless of estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk. Cholesterol management is a cornerstone of therapy in diabetes management, and patients may require more aggressive lipid-lowering therapy depending on individual risk.
When it comes to CKD, it is important to consider renal dose adjustments when prescribing statins. Pharmacists can play a vital role by recommending switching to another statin that does not require renal dosing or adjusting the dose when necessary. CKD is considered a risk-enhancing factor for ASCVD, and these patients often require closer monitoring to optimize therapy and reduce cardiovascular risk.
Pharmacy Times: What are the most common challenges patients face with statin adherence, and how can pharmacists help address them?
Gronniger: Many patients arrive with concerns about statins due to hearing negative experiences from their family and friends, so education on the benefits of statins tailored to the patient’s medical history is essential. While statin-associated adverse effects can happen, experiencing adverse effects with one statin does not necessarily mean a patient will not be able to tolerate another statin. In our practice, we oftentimes try multiple statins or decrease the dose to see if it is better tolerated. For example, switching from a lipophilic to a hydrophilic statin may be better tolerated. Providing education, reassuring patients that they can reach out with questions or concerns, and informing them about alternative treatment options can significantly improve statin adherence.
Pharmacy Times: What emerging therapies or technologies are you most excited about in the future of cholesterol management, and why?
Gronniger: There are numerous lipid-lowering therapies actively being researched, which is very exciting. The ones I am looking out for are lipoprotein(a) [Lp(a)] lowering therapies, oral PCSK9 inhibitors, a new cholesteryl ester transfer protein (CETP) inhibitor, and gene editing therapy. Lp(a)-lowering therapies are especially exciting, as we currently do not have medications that target it available. Currently, the only available medications that have shown a reduction in Lp(a) are subcutaneous PCSK9 inhibitors, which can lower it by 20% to 30%; however, they are not indicated for this purpose. Some of the current medications in trials have been shown to decrease Lp(a) by 80% to 95%.
Oral PCSK9 inhibitors are exciting as well, as some patients are needle-phobic and would like to avoid injection therapies. So far in trials, they have been shown to reduce LDL by 50% to 60%, which is equivalent to their subcutaneous counterparts. Another oral medication, obicetrapib, is currently being studied and has been shown to reduce LDL by 50% and Lp(a) by 20% to 30%. Although past CETP inhibitors were shown to increase blood pressure, obicetrapib has been well-tolerated in early trials.
Lastly, gene-editing therapies have shown promising LDL reduction in phase 1 trials after only 1 injection, which could be a game changer in cholesterol management. While all of these emerging therapies have demonstrated promising reductions in LDL and Lp(a), I look forward to seeing whether they will also show reductions in MACE.
