What treatment is recommended for a patient with statin intolerance and a LDL-C of 200 mg/dL?

The recommended treatment for a patient with statin intolerance and an LDL-C of 200 mg/dL is to initiate evolocumab 140 mg subcutaneously every 2 weeks. Evolocumab is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, which is known to significantly lower LDL cholesterol levels. It provides an effective alternative for patients who are unable to tolerate statins, such as those who experience muscle-related side effects.

In this clinical scenario, the primary goal is to lower the LDL-C to a safer level. Since the patient has already demonstrated statin intolerance, using a PCSK9 inhibitor is a suitable approach. Evolocumab has been shown through clinical trials to effectively reduce LDL-C levels by up to 50-60%, making it a powerful option for achieving desired LDL targets.

Other treatments, such as colesevelam, may also help manage cholesterol levels, but they typically do not achieve the LDL reduction that PCSK9 inhibitors do in this setting of severe LDL elevation and statin intolerance. Similarly, while gemfibrozil can lower triglycerides and may have a modest effect on LDL, it is not a first-line treatment for isolated elevated LDL-C in statin