Which Medications Treat High Cholesterol—and How to Choose Between Bempedoic Acid (Nexletol) and Statins

When managing hyperlipidemia—elevated levels of cholesterol or triglycerides in the blood—clinicians rely on evidence-based pharmacotherapy tailored to individual cardiovascular risk profiles. Among the most widely prescribed agents are statins, which inhibit HMG-CoA reductase and significantly reduce low-density lipoprotein cholesterol (LDL-C), total cholesterol, and triglycerides while modestly increasing high-density lipoprotein cholesterol (HDL-C). Commonly used statins include atorvastatin, rosuvastatin, simvastatin, and pravastatin, each available under multiple brand names globally.

For patients who cannot achieve LDL-C targets on statin monotherapy—or who experience statin-associated muscle symptoms (SAMS) or other contraindications—combination therapy is often indicated. One well-established option is bempedoic acid, marketed in the U.S. and several other countries as Nexletol® and, in fixed-dose combination with ezetimibe, as Nexlizet®. In China, bempedoic acid is approved and commercially available as Saiximei® (a branded formulation of bempedoic acid tablets), sometimes colloquially referenced alongside ezetimibe-containing products—but it is critical to clarify that Saiximei® contains bempedoic acid alone, not ezetimibe. Ezetimibe, a selective cholesterol absorption inhibitor, is available separately (e.g., as Ezetrol®) or in combination with statins (e.g., Vytorin®, which pairs simvastatin with ezetimibe).

The choice between initiating a statin versus adding bempedoic acid—or combining either with ezetimibe—depends on multiple clinical factors: baseline LDL-C level, 10-year atherosclerotic cardiovascular disease (ASCVD) risk, tolerability, drug–drug interaction potential, renal and hepatic function, and patient preference. Bempedoic acid offers a non-statin mechanism with minimal systemic exposure and no known myotoxicity, making it particularly valuable for statin-intolerant individuals. However, it is not a substitute for high-intensity statin therapy in high-risk patients who tolerate statins well.

Clinical guidelines—including those from the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS)—emphasize LDL-C lowering as a primary treatment goal, with target thresholds stratified by risk category. Shared decision-making, regular lipid monitoring, and assessment of adherence and side effects remain essential components of long-term management.