Addition of Bile Acid Sequestrants to Statins May Further Lower LDL-C

Statin therapy concent photo
Statin therapy concent photo
The addition of bile acid sequestrants to statin therapy may further reduce LDL-c in patients intolerant to maximal statin dosage.

The addition of bile acid sequestrants to statin therapy may further reduce low-density lipoprotein cholesterol (LDL-c) in patients intolerant to maximal statin dosage, according to from the results of a meta-analysis published in the American Journal of Medicine.

A total of 9 randomized controlled trials (n=1324) in which the effect of statin therapy alone vs in combination with bile acid sequestrants were examined in patients with hyperlipidemia, were included in the meta-analysis. In 3 trials, maximum bile acid sequestrant therapy (ie, ≥24 grams cholestyramine or ≥3.75 grams colesevelam per day), was used.

Patients who were prescribed bile acid sequestrants plus statins had a 16.21% (95% CI, 9.71-22.70) higher percentage change in LDL-c compared with patients who were prescribed statins alone (P <.001). Treatment efficacy was not affected by study years/lengths, type of statin, statin intensity, or type of hypercholesterolemia.

The choice of bile acid sequestrant, was found to be marginally associated with treatment efficacy. Patients who took the maximum vs lower strength bile acid sequestrant medications had a greater percentage change in LDL-C from baseline (14.47%; 95% CI, 3.65-25.29; P =.0087).

Study limitations include the lack of high-quality data, particularly in the absence of large-scale, multicenter randomized clinical trials. In addition, the rates of adverse events or compliance to bile acid sequestrants could not be assessed.

“[C]linicians should be aware that in [patients undertaking] primary prevention who cannot tolerate statins at all, the addition of ezetimibe plus colesevelam will greatly increase LDL-C lowering and could help clinicians reduce risk [for] cardiovascular atherosclerotic disease,” noted the study authors.


Alder M, Bavishi A, Zumpf K, Peterson J, Stone NJ. A meta-analysis assessing additional LDL-C reduction from addition of a bile acid sequestrant to statin therapy [published online May 13, 2020]. Am J Med. 2020;S0002-9343(20)30372-7. doi: 10.1016/j.amjmed.2020.03.056