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.

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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