Nonstatin Prescriptions Increasing, Still Behind Statins in ASCVD, With Michael Blaha, MD, MPH

Since 2019, nonstatin lipid-lowering therapy (LLT) prescription has expanded substantially among patients at risk for atherosclerotic cardiovascular disease (ASCVD), according to a recent study; however, it still has not closed the gap with statins.1

A plethora of recent research has reinforced the efficacy of nonstatin LLTs in the reduction of ASCVD risk, and several therapies have received approval to lower LDL-C and other atherogenic lipoproteins. Among these are ezetimibe, bile acid sequestrants, PCSK9 inhibitors, bempedoic acid, fibrates, icosapent ethyl, and niacin. Additionally, recently published guidelines have recommended the addition of nonstatin LLTs when statin therapies are insufficient. However, implementation has lagged behind that of statins over the years.2

“In some cases, clinicians think of statins as a simple yes or no,” Michael Blaha, MD, MPH, professor of cardiology and epidemiology, director of clinical research for the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, and co-author of the present study, told HCPLive. “Of course, the new guidelines are really going to push people to think more about LDL goals. Statins will remain the cornerstone of therapy, but maybe only step 1. Maybe you need step 2 or step 3 after that, with the addition of nonstatin therapy and, of course, more appreciation of statin intolerance and how best to handle that."

This cross-sectional study utilized IQVIA’s National Prescription Audit, which collects data from January 2019 to December 2024. Bhala and colleagues quantified dispensed prescriptions for ezetimibe, bempedoic acid, and the fixed-dose combination of bempedoic acid and ezetimibe, as well as alirocumab, icosapent ethyl, and evolocumab. Older nonstatins without recent cardiovascular outcome data were excluded.1

Investigators recorded roughly 94.8 million nonstatin and 1.35 billion statin prescriptions dispensed between 2019 and 2024. Annual nonstatin prescriptions rose by roughly 10.7 million (10.9 to 21.6 million), while statin prescriptions increased by roughly 18.2 million (217.3 to 235.5 million). Additionally, the ratio of nonstatin to statin prescriptions rose from 1:20 in 2019 to 1:11 in 2024. Blaha and colleagues also grouped prescribers as cardiology, endocrinology, primary care physicians (PCPs), advanced practice practitioners (APPs), and others. The team used American Medical Association Physician Masterfile counts to estimate prescriptions per active clinician for a specialty-specific comparison.1

Of the included nonstatin therapies, ezetimibe was the dominant therapy throughout the study period, reaching about 15.3 million prescriptions annually and accounting for roughly 2/3 of all nonstatin prescriptions. Bempedoic acid likewise rose from 39,600 prescriptions in 2020 to 395,202 in 2024; however, overall volume was consistently lower than other therapies. Evolocumab prescriptions rose from 757,000 in 2019 to 3.56 million in 2024 (absolute increase roughly 2.81 million). Alirocumab prescription volumes rose through 2023, but decreased again in 2024; similarly, icosapent ethyl rose from 2019 to 2022 before declining through 2024.1

After normalization per 100 clinicians, cardiologists exhibited the highest prescribing intensity for all nonstatin therapies. In 2024, cardiologists wrote roughly 98 ezetimibe prescriptions per 100 clinicians, versus 21 per 100 among PCPs. For evolocumab, cardiologists covered 48 prescriptions per 100 clinicians, compared to roughly 2-3 per 100 among PCPs and APPs.1

According to Blaha and colleagues, these prescription trends align with recent guideline emphasis on combination LDL-C-lowering strategies, as well as rapidly accumulating evidence for ezetimibe, PCSK9 inhibitors, and bempedoic acid. However, the team also noted that nonstatins continue to represent only a small share of overall LLT use.1

“I think the education gap is closed – really, it’s more of an implementation gap now. Sometimes, that’s resistance from the patient, or statin intolerance, or similar things,” Blaha said. “I think the next step is with the patients who are unwilling to take a statin, or unable to take a statin, or unable to take a maximal dose of a statin. How can we implement nonstatin therapies in an evidence-based way?”

Editors’ Note: Blaha reports disclosures with Bayer, Boehringer Ingelheim, Eli Lilly, Genentech, Merck & Co., Novartis, and others.

References

1. Burka S, Dzaye O, Cao T, et al. US trends in prescribing nonstatin lipid-lowering therapy, 2019-2024. JAMA Cardiology. Published online April 22, 2026. doi:10.1001/jamacardio.2026.0844

2. Kamanu C, Karalis DG. The Role of Non-Statin Lipid Lowering Therapies to Reduce ASCVD Events in Primary Prevention. Curr Atheroscler Rep. 2025;27(1):46. Published 2025 Apr 2. doi:10.1007/s11883-025-01283-1