Pharmacists Key to Lp(a) Counseling and Lipid Optimization

In an interview with Pharmacy Times, Dinesh Kalra, MD, MBA, FNLA, FACC, FAHA, chief of cardiology at the University of Louisville School of Medicine and president of the National Lipid Association (NLA), discussed how imaging complements lipoprotein(a) [Lp(a)] testing, pharmacists' role in counseling, and why Lp(a) testing retains value after the negative topline Lp(a)HORIZON results.

Kalra said imaging has taken on an expanded role in prevention guidelines because many younger individuals with subclinical atherosclerosis have a low 10-year risk but a much higher lifetime risk. US and European guidelines support subclinical atherosclerosis imaging when clinicians are uncertain about a patient's risk, though it adds little for patients with established coronary disease who warrant a statin regardless. In those uncertain cases, imaging both clarifies risk and motivates patients, who are more likely to stay on medications once they know they have atherosclerosis. It also helps set low-density lipoprotein (LDL) cholesterol goals: the higher the coronary calcium score, the lower the target. Most imaging today relies on coronary calcium scoring, with carotid and iliofemoral ultrasound and, in select patients, coronary CT angiography to detect noncalcified plaque.

Kalra described pharmacists as critical members of the prevention team. They can counsel patients to have Lp(a) tested at least once, follow up on lipid optimization when physicians lack time, and reinforce adherence and refills. Pharmacist- and team-run programs tend to achieve better risk factor control than physician-run programs alone, he noted, and pharmacists can help patients understand that muscle aches while taking a statin are not necessarily caused by the drug.

Kalra cautioned against abandoning Lp(a) testing after Lp(a)HORIZON (NCT04023552) did not meet its primary end point, noting that full data and subgroup analyses remain unpublished and that multiple other agents remain in development. He also highlighted cascade screening of family members, since Lp(a) is genetically determined, as a way to extend risk reduction to entire families.