I was curious about why bempodeic acid + ezetimibe seemed to be the last option recommended by cariology to lower LDL choelsterol.
I had tried statins in the spring/summer of 2025 but had numerous very bad side effects, confirmed by dropping the statins, restarting at half dose and then trying with a different statin.
I was later put on Praluent, a PCSK9 inhibitor. Unfortunately 4 days later I had symptoms of sepsis, and the next day was hospitalized for a week on IV antibiotics. One week after discharge I began to experience various muscle, joint and tendon pain issues. We have no way of knowing if this was caused by the PCSK9 inhibitor or was post sepsis syndrome. 9 months later, it starts to look like it may have been post sepsis syndrome. The only thing we can say for sure is that ending Praluent ended my 5x to 10x/day muscle cramps.
Now there has been discussion of being put on bempodoeic acid instead. That made me wonder – why is it a 3rd line choice?
As of now, it is no longer is a 3rd line choice and should be considered as a 2nd option if statins cannot be tolerated. PCSK9 inhibitors – until now – have been a self injected medication, which adds complications and risks. (An oral version of a PCSK9 inhibitor just became available – known as lipfendra. This drug is reported to have a half life of 10 hours – versus 15-20 days for Repatha/Praluent injectables. The latter are based on monoclonal antibodies which are very large molecules and for those of us with immune hypersensitivity, can lead to bad immune system reactions. Lipfendra is based on peptides that far smaller and may be less likely to activate an immune response – or so I have read.)
Nonstatins remain underutilized12–14 due to clinical inertia, misconceptions that only statin therapy reduces ASCVD risk, medication access barriers for brand-name products, concerns about potential side effects, and perceived lack of need by clinicians and patients
Dietary changes can reduce LDL-C, but for most people, the reduction is very small.
Probably the largest benefits come from weight loss, physical activity and eating low glycemic index foods (avoid sugar and refined starches) and reducing triglyceride levels.
More on the new guidelines
He also listed two important changes. First, that every adult should be tested for lipoprotein(a), or Lp(a), at least once. Testing of first-degree family members is recommended when Lp(a) is elevated.
Second, that calcium score testing in men aged 40 years or older and women aged 45 years or older is recommended when the decision about lipid-lowering therapy is at intermediate risk.
A calcium score above 100 should have a goal LDL cholesterol of under 70. Above 1,000, the goal LDL is under 55.
“[R]ather than treating based on a single number — the LDL [cholesterol levels] — clinicians will now use an estimated total cardiovascular risk assessment. They will also look at ‘risk-enhancing’ factors — e.g. family history, chronic kidney disease, inflammatory conditions, high levels of lipoprotein[a] — and treat based on the patient’s risk level,” Hoedebecke said.
2026 cholesterol guidelines: Why 1 in 3 adults are above safe limits
No one has ever asked me to have my Lp(a) level measured, nor to have my Calcium Score measured. Under the older guidelines, LDL was to be under 100 or 129. In my medical records, one hospital shows a goal of <100 and the other shows a goal of <129.
At my last lipids test, my LDL was 71. I cannot take statins or PCSK9 inhibitors. That prior score was due to diet only – mostly consuming soluble fiber which binds to the bile acid in the intestines, which then is excreted in feces. Bile acid is made up mostly of cholesteol so this has a direct effect of removing cholesterol from your blood. A secondary removal occurs in that the liver makes new bile by pulling cholesterol out of the blood.
