Start With the Statin, Then Work the Problem: Mary Katherine Cheeley's Framework for Lipid Therapy Optimization

Mary Katherine Cheeley, PharmD, BCPS, CLS, FNLA, walks through her order of operations for patients who aren't meeting low-density lipoprotein cholesterol (LDL-C) goals: never abandon the statin, target the next therapy to the patient's specific lipid goal, and always prioritize what the patient will actually stick with. She covers her preference for PCSK9-targeted therapies given their adherence advantages, her approach to needle-hesitant patients, and how her medication access team at Grady handles prior authorizations and copay assistance. Her closing principle: write out every option, explain each one, and let the patient choose—because buy-in drives adherence.

Q: With the growing complexity of lipid-lowering pharmacotherapy—statins, ezetimibe, PCSK9 inhibitors, bempedoic acid, fibrates, omega-3s—how should pharmacists approach therapy optimization, particularly when patients aren't meeting their LDL-C goals?

Mary Katherine Cheeley, PharmD, BCPS, CLS, FNLA: I love to really tailor a patient’s medications to their risk, their lifestyle, and their access points. Let me take you into my brain when I’m in a clinic room, because I think this is the best way to describe it. We always start with a statin. Always. We want them to be adherent to their statin. I’m very passionate about statin intolerance—if you can’t tolerate your statin, we’re not giving up on it. The vast majority of patients can tolerate something. It won’t be enough for some people, but they can tolerate something. I am very much the provider that’s going to say, “Your 10 milligrams of rosuvastatin once a week—that’s something. Let’s go there; let’s add therapy so we can get to where we need to get to. We’re not going to give up on the statin in a month or two — we’re going to go up on the dose, and if it doesn’t work, we’ll go back down. We found something we can do. So we get that done, we get them on something, we don’t abandon it, but we move on to the next one—because we cannot waste time when we’re talking about something the patient has had ongoing for 30 years or longer.

Past that point, I look at what the patient’s main goal is. Is it triglyceride reduction? Is it A1c reduction in addition to their LDL-C? Is it just plain LDL-C reduction? Is it non-HDL? Where do we need to go, and I’ll target my next therapy for that? I tend to reach for PCSK9 monoclonal antibodies or PCSK9-targeting therapies more than anything because it’s a lot easier for the patient—and I think about it in terms of access. If they can get to the pharmacy once a month to get their injections, or every three months for some insurers, I know they’re covered. If I can get them into the clinic every six months for inclisiran at the maintenance dose, I know they’re covered, and I don’t have to worry about their adherence as much. They’re still on their statin—we’re still working on that—but those therapies have had the biggest success with my patients. Some patients are really skittish about needles, but if you show them the auto-injector, 9.9 out of 10 of them are going to be fine with it, and they actually prefer to do it at home. I do have some patients who want to come in and get their inclisiran in the clinic—that’s great too.

I don’t reach for other meds as often. I work in a specialized lipid clinic, so most of my patients have a large gap we need to fill. If it’s more than 20%, I’m not going to reach for ezetimibe. If it’s around 40%, I’ll think about the combination of bempedoic acid and ezetimibe, but that’s something they have to take every day, which is hard for patients, and there is that increased risk of non-adherence. That’s always in the front of my mind — what will they be successful with? Omega-3s are certainly something I was a little bit hesitant to reach for because of the pill burden, but the data is so compelling. A lot of my patients have complex cardiometabolic disease, and those patients really benefit from omega-3s—as well as from GLP-1s. From a pharmacoequity standpoint, I wouldn’t be doing my job if I didn’t break down every barrier to getting them that therapy when it’s clinically appropriate. My order of operations: you’ve got to be on your statin.

We will get you on something—even if it’s just a baby dose of it, I want that on board. Past that, we’ll see how far we need to go with LDL-C management, and we’re going to pick something that will get us there, hopefully on the first try. I always try to think about it in terms of what’s easiest for the patient from an adherence standpoint.

I’m also blessed to have a really amazing medication access team at Grady. We have medication access coordinators who get patients copay cards, foundation assistance, and PAP enrollment. They do our prior authorizations for us, so that piece I never have to worry about with my patients. We will get you something — it might take us a minute, but we will get it for you. I think that also really helps patients have buy-in into the process.

It is really, really important to establish the LDL-C goal upfront with patients so they know what they’re working toward and to keep checking it and maintain those targets. I’m so glad the guidelines updated and finally got that back in there with such strong recommendations, because our patients crave that—they want to know what they’re working toward. That has always been a huge help. It also helps when we’re telling a patient they need to do an injection and explaining why. I will consistently write down every option—probably 10 things—on a piece of paper and go over them with the patient: “We can’t do this one because it’s not going to get us where we need to go. We can’t do this one because it’s not the right one for you.” And then I let the patient choose—because when they have buy-in, they are going to be more adherent to that therapy.