How does one go about intensifying drug therapy? Unless contraindicated because of patient tolerance or adherence issues, up-titration of the statin to the maximum tolerated dose would be the first step. After that, if tolerance and adherence appear to be satisfactory and yet the LDL cholesterol levels remain unacceptably high, then adding ezetimibe, niacin, or bile acid sequestrants would all be acceptable as effective drugs of choice for further lowering LDL. Fibrates or prescription omega 3 fatty acids are typically more effective for lowering triglycerides, and again, this is not really the primary defect of FH.
As always whenever considering multidrug regimens for any patient, it is necessary to weigh the potential for benefit versus the potential for harm, and certainly adverse effects, increased cost, and decreasing adherence are all important considerations. J Clin Lipidol. 2011; 5(6).
