Lipid management therapy reference (2026)

Lipid management therapy in 2026 organises around foundational and add-on options.

Foundational: statins (atorvastatin, rosuvastatin, simvastatin, others) remain first-line for nearly all patients with elevated LDL cholesterol or established cardiovascular disease. High-intensity statin therapy is the modern preference for most patients with established disease.

Add-on for inadequate LDL response on maximally-tolerated statin: ezetimibe (oral, inhibits cholesterol absorption); PCSK9 monoclonal antibodies (alirocumab, evolocumab, given by injection every 2 to 4 weeks); inclisiran (siRNA-targeted PCSK9 reduction, given by injection every 6 months); bempedoic acid (oral, ATP-citrate lyase inhibitor, particularly useful in statin-intolerant patients).

Lp(a)-targeted: pelacarsen (ASO targeting LPA mRNA) in late-stage cardiovascular outcomes trials; lepodisiran (siRNA targeting LPA) in late-stage trials; olpasiran in late-stage trials. If outcomes-positive, this would establish a new lipid-target category.

ANGPTL3-targeted: evinacumab (monoclonal antibody, approved for homozygous familial hypercholesterolemia); zodasiran (siRNA targeting ANGPTL3) in late-stage trials.

Other: omega-3-fatty-acid-derived therapy (icosapent ethyl) in selected patients; fibrates for severe hypertriglyceridemia.

Emerging tier: oral PCSK9 inhibitor programs are in late-stage trials, with the proposition of high-efficacy LDL reduction without injection delivery.

The diagnostic-pathway question matters. Lp(a) testing (covered in earlier rounds) is the structural diagnostic-pathway investment that defines the addressable population for Lp(a)-targeted therapy.