What class is first-line pharmacologic therapy for hyperlipidemia?

• A. Niacin
• B. Fibrates
• C. Statins
• D. Bile acid sequestrants

Answer: (C)

Statins are first-line therapy because they directly lower the most problematic lipid, LDL cholesterol, and do so in a way that consistently reduces cardiovascular events. They inhibit HMG‑CoA reductase in the liver, which lowers hepatic cholesterol synthesis. When liver cholesterol falls, it upregulates LDL receptors and clears more LDL from the blood, producing a substantial drop in LDL-C—often 30–50% or more, depending on the drug and dose. Beyond lipid changes, statins have a strong, proven record in large randomized trials showing reduced heart attacks, strokes, and cardiovascular mortality, making them the preferred cornerstone of therapy for most patients with elevated ASCVD risk.

Other agents exist to tailor therapy to individual lipid patterns (eg, fibrates for high triglycerides, bile acid sequestrants for LDL lowering with tolerability considerations, niacin for HDL and TG effects), but they either don’t provide the same consistent cardiovascular risk reduction or are reserved for specific situations.