Dear Dr. Roach: In a recent column, you wrote about reducing cholesterol with the help of statins along with a PCSK9i, such as Repatha or Praluent. My question is: Are these PCSK9is at all beneficial if one cannot take statins?

— D.C.S.

Dear D.C.S.: Yes, PCSK9 inhibitors are very effective at lowering cholesterol and reducing the risk of heart attack in high-risk people. Because these drugs are given by injection and are quite expensive, they are not usually the first-line treatments. We have decades of experience using statins, so they remain the first choice for most.

However, if a person cannot take a statin, or one of the alternatives such as bempedoic acid, then PCSK9i drugs are a very reasonable choice. In people with familial high cholesterol and extraordinarily high levels of

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