J Formos Med Assoc. 2026 Apr 28:S0929-6646(26)00449-3. doi: 10.1016/j.jfma.2026.04.111. Online ahead of print.
ABSTRACT
Statins are the cornerstone of lipid-lowering therapy for the prevention of atherosclerotic cardiovascular disease (ASCVD); however, many patients are unable to achieve guideline-recommended low-density lipoprotein cholesterol (LDL-C) targets because of suboptimal tolerance to statins. The 2026 Taiwan Society of Lipid and Atherosclerosis (TSLA) Consensus Statement presents an updated, evidence-based framework for the identification and management of patients receiving suboptimally tolerable statins (STS)-a pragmatic concept that extends beyond the traditional and restrictive definition of statin intolerance (SI). STS encompasses patients who are unable to maintain recommended statin intensity because of real or perceived adverse effects, even when formal SI criteria are not met, thereby addressing a major treatment gap in real-world practice in Taiwan. This consensus integrates contemporary international evidence and Taiwanese guidelines, including the 2025 Taiwan cholesterol management pathway, and proposes structured, risk-based algorithms for STS management. A tiered therapeutic strategy is recommended: extremely high-risk patients should receive early combination therapy with ezetimibe and bempedoic acid, with prompt escalation to PCSK9 inhibition-based agents if LDL-C targets (<55 mg/dL) are not achieved. In high- and very high-risk patients, ezetimibe is the first-line add-on therapy, followed by bempedoic acid and PCSK9-targeted agents as needed, while lifestyle intervention and shared decision-making are emphasized in lower-risk groups. Non-pharmacological options are also reviewed; however, robust cardiovascular outcome data remain limited. By bridging conceptual and policy gaps between SI and STS, this consensus promotes a patient-centered, precision-based approach to improving LDL-C goal attainment and reducing residual ASCVD risk.
PMID:42055832 | DOI:10.1016/j.jfma.2026.04.111