EP146: Ezetemibe - What is it and What Does it Do? With Dr. Karam Kostner

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Podcast Summary Introduction Dr. Warrick Bishop, a practicing cardiologist and author focused on patient education in heart health, hosts this episode featuring Dr. Karim Kostner, an internationally recognized lipid management expert. The episode explores ezetimibe (marketed as Ezetrol), a cholesterol-lowering medication that has gained renewed clinical attention in recent years for its effectiveness in combination with statins. Key Takeaways: Ezetimibe is a cholesterol absorption inhibitor—the only drug in its class—that works by blocking a receptor in the intestine responsible for cholesterol reabsorption, reducing cholesterol levels by 20-25% in individuals. The medication remains primarily in the gut with minimal bloodstream absorption, making it very well tolerated with no significant muscle-related side effects, unlike statins, and causes only mild gastrointestinal discomfort in some cases. Individual response to ezetimibe varies based on genetics; people who are efficient dietary cholesterol absorbers (about 20% of the population) respond better than those whose bodies produce more cholesterol internally. Adding ezetimibe 10mg to a low-dose statin produces the same LDL cholesterol reduction as doubling the statin dose, making it a superior strategy for patients who don't tolerate higher statin doses. Combining ezetimibe with high-dose statins can achieve up to 60-70% LDL cholesterol reduction—a dramatic improvement compared to results from 5-10 years ago. The IMPROVE-IT trial demonstrated that adding ezetimibe to simvastatin reduces atherosclerotic cardiovascular events, including repeat heart attacks, unstable angina, and need for revascularization procedures. Achieving very low LDL cholesterol levels (under 1.7-1.8 mmol/L) through ezetimibe and statin combinations enables actual regression or stabilization of arterial plaque buildup, reducing heart attacks and strokes. Ezetimibe should not replace statins as first-line therapy since statins are more effective (50-60% reduction) and have more extensive clinical trial evidence, but works excellently as an add-on therapy. The medication is affordable at $13-14 monthly and is available as fixed-dose combinations with statins or co-packs, allowing patients to pay only one prescription fee. For statin-intolerant patients, ezetimibe can be used alone or combined with low-dose statins taken intermittently (1-3 tablets weekly) to achieve meaningful cholesterol reduction while maintaining tolerability.