What are the indications for using ezetimibe before PCSK9 inhibitors?
Ezetimibe is recommended for use before a PCSK9 inhibitor when a patient is not able to reach their LDL-C target with statin therapy. This is supported by two simulation studies from large populations of very high-risk patients showing that ezetimibe plus statin therapy was able to lower LDL-C to <70 mg/dL (1.8 mmol/L) in most patients, and the TST trial of patients with ischemic stroke used ezetimibe as second-line therapy to achieve the LDL-C targets. Very high risk patients include those with a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions, such as age 65, heterozygous familial hypercholesterolemia, diabetes, hypertension, and chronic kidney disease. 