Q&A: How Pharmacists Can Manage Statin Intolerance and Improve LDL-C Control

In an interview with Pharmacy Times, Joseph Saseen, PharmD, BCPS, BCACP, CLS, professor and associate dean for clinical affairs in the Department of Clinical Pharmacy at the University of Colorado Anschutz Skaggs School of Pharmacy and Pharmaceutical Sciences; and Joel C. Marrs, PharmD, MPH, FAHA, FASHP, FCCP, FNLA, BCACP, BCCP, BCPS, CLS, cardiology ambulatory clinical pharmacist at Cheyenne Regional Medical Group Heart and Vascular Institute and associate professor at the University of Colorado School of Medicine, discussed key updates in the 2026 dyslipidemia guidelines and their implications for clinical and pharmacy practice.¹

Marrs highlighted the importance of addressing statin-associated muscle symptoms in practice, noting that although approximately 10% of patients report such effects, many cases can be managed through dose adjustments, alternative statin strategies, or combination therapy with nonstatins. He also emphasized adherence optimization strategies, including medication synchronization, 90-day fills, and cost barrier mitigation, as key pharmacist-driven interventions.

Saseen further underscored that statin intolerance requires careful evaluation, including trialing multiple statins, ruling out secondary causes, and incorporating shared decision-making—particularly in patients with misinformation-related refusal. He reinforced that cardiovascular benefit outweighs risk in most patients and that perceived adverse effects may be influenced by nocebo effects, as demonstrated in the phase 4 SAMSON trial (NCT02668016).

Pharmacy Times: Can you please introduce yourself?

Joseph Saseen, PharmD, BCPS, BCACP, CLS: Hello. My name is Joseph Saseen. I’m an associate dean for clinical affairs and a professor at the University of Colorado. I’m also a past president of the National Lipid Association and a member of the 2026 dyslipidemia guideline writing committee.

Joel Marrs, PharmD, MPH, FAHA, FASHP, FCCP: I’m currently a cardiology ambulatory clinical pharmacist with Cheyenne Regional Medical Group, Heart and Vascular Institute, and also an adjunct associate professor at the University of Colorado School of Medicine. Currently, in my practice, I see patients for both primary and secondary prevention of cardiovascular disease in our cardiology clinic.

Pharmacy Times: New lipid-lowering therapies are included in the guidelines. How do they fit into treatment algorithms?

Saseen: Therapies such as bempedoic acid, inclisiran (Leqvio; Novartis), and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are clearly outlined as nonstatin therapies that lower low-density lipoprotein (LDL) cholesterol and have supporting evidence.

They are recommended primarily when patients cannot achieve LDL goals on statin therapy. That can include patients who do not tolerate statins or cannot tolerate the dose needed. These agents are used as add-on therapies, although in some cases, such as statin intolerance, they may be used earlier. They differ in potency. PCSK9 inhibitors and inclisiran provide more robust LDL lowering, while bempedoic acid is more similar to ezetimibe in terms of reduction. There are also newer therapies emerging that were approved after the guideline evidence cutoff, which will continue to expand treatment options.

Pharmacy Times: The guidelines comprehensively address statin-associated muscle symptoms. What evidence-based strategies should pharmacists use to help patients stay on therapy?

Marrs: There definitely is a full section on statin-associated safety issues, and one of those is muscle symptoms. Roughly about 10% of the population, if you look at real-world data, does develop some sort of muscle symptom and can’t necessarily tolerate maximum statin therapy. Being able to talk to patients about trying to keep them on an appropriate statin based on their risk profile is important. I think being honest with them that there are potential [adverse] effects, but that most are not very common, is key.

Muscle symptoms are probably the most common, but working with patients—whether that’s trying alternative dosing strategies or adjusting therapy—is important. Also addressing barriers like cost is important, as well as adherence strategies. For example, synchronizing medications so they’re filled at the same time or providing 90-day supplies can help improve adherence.

Saseen: Statin intolerance can mean many different things. For patients with symptoms, recommendations include trying more than one statin, ruling out secondary causes, and managing symptoms appropriately. In many cases, using a nonstatin drug in combination with a lower statin dose is necessary to achieve LDL goals.

There is also a group of patients who refuse statins due to misinformation. That is equally challenging. It requires shared decision-making and clear communication to help patients understand the benefits vs the risks. We should emphasize benefit over risk, because there is more benefit than risk with these therapies. Muscle symptoms can occur, but they are often overestimated. The SAMSON trial showed that perceived [adverse] effects can occur even with a placebo.

Pharmacy Times: The guidelines emphasize earlier intervention in patients with familial hypercholesterolemia starting in childhood. What role should pharmacists play?

Saseen: Patients with familial hypercholesterolemia [FH] can be heterozygous or homozygous. Homozygous FH is rare but severe, with very high LDL levels and early cardiovascular risk.

Heterozygous FH is more common, with LDL levels typically above 190. Patients with family history should be screened early. If identified, they should be treated, often with statin therapy, which is approved for use in children when appropriate. In adults, risk assessment now starts at age 30. LDL levels in the 160-to-189 range should also be taken seriously, rather than waiting until 190.

Pharmacy Times: How do the new triglyceride management recommendations affect the use of omega-3 fatty acids and fibrates in pharmacy practice?

Marrs: Excellent question. There have been some changes in triglyceride management in these new guidelines. Statins remain the primary therapy for reducing atherosclerotic cardiovascular risk. When triglycerides are elevated, the focus shifts to understanding the reason for lowering them, which is primarily to reduce the risk of pancreatitis.

Fibrates and omega-3 fatty acids are still options, but they may be used more selectively. For example, fibrates may be used when triglycerides are above 500 and particularly above 1000, where the risk of pancreatitis is highest. There is also a recommendation for icosapent ethyl in patients with established ASCVD [atherosclerotic cardiovascular disease] or diabetes with risk factors, as it has evidence for reducing cardiovascular risk. Additionally, there are newer therapies emerging for specific conditions, such as familial chylomicronemia syndrome, which will likely expand treatment options moving forward.

Pharmacy Times: Is there anything else that you would like to add?

Saseen: I’ll emphasize that goals are back, which is important for clinicians. We also expect to see increased use of coronary artery calcium scoring.

Guidelines are based on the best available evidence at a given time, but new therapies and studies continue to emerge. Some newer evidence supports even more aggressive LDL lowering. Clinicians should stay up to date as the field continues to evolve.

Marrs: I think this is a huge opportunity for pharmacists to expand their role in helping patients optimize dyslipidemia management and reduce overall cardiovascular risk. That includes everything from lifestyle counseling—diet, exercise—to therapy initiation and optimization.

Another key piece is monitoring. With the return of LDL-C goals, it’s important to recheck lipids and adjust therapy as needed. Pharmacists can play a major role in ensuring patients stay on track and achieve those goals.

REFERENCE

1. Halpern L. Earlier intervention, lower cholesterol: ACC/AHA release updated dyslipidemia management guidelines. Pharmacy Times. March 18, 2026. Accessed April 21, 2026. https://www.pharmacytimes.com/view/earlier-intervention-lower-cholesterol-acc-aha-release-updated-dyslipidemia-management-guidelines