LDL Still High Despite Statins? Advanced Cholesterol Treatment in Singapore
- Dr Chan Po Fun
- Mar 8
- 9 min read
Updated: 3 days ago
Dr Chan Po Fun [MBBS, MRCP, FRCP (UK), FAMS (Cardiology)] is a consultant cardiologist in Singapore with a focused practice in lipid management and cardiovascular risk reduction.
If your LDL cholesterol is still high despite taking a statin, you are not alone. And you have not run out of options.
Statins are the most effective first-line treatment for lowering LDL, but for a significant proportion of patients, they are not enough to reach the LDL target their cardiovascular risk requires. This is not a personal failure or a sign that nothing will work. It is a recognised clinical situation with clear, guideline-supported solutions.
In short: Some patients continue to have high LDL cholesterol even on appropriate statin therapy — due to genetics, very high cardiovascular risk, statin intolerance, or elevated Lp(a). Several advanced treatments are now available in Singapore, including injectable therapies that can lower LDL by a further 50–60%. This article explains who needs them, what the options are, and what a specialist assessment involves.
“In clinical practice, I frequently see patients whose LDL cholesterol remains above target despite appropriate treatment,” says Dr Chan Po Fun, Consultant Cardiologist in Singapore.
This situation is more common than many realise.
Today, several advanced cholesterol treatments are available in Singapore, including PCSK9 inhibitors (Inclisiran [Leqvio], Evolocumab [Repatha]), which can significantly lower LDL cholesterol when statins alone are insufficient.
"When LDL cholesterol remains above target despite statins, additional therapies may be needed to adequately reduce cardiovascular risk,” says Dr Chan Po Fun
Some patients are surprised to learn that modern cholesterol therapies can now lower LDL cholesterol to levels that were previously difficult to achieve with statins alone.
Could This Apply to You?
You may benefit from further cholesterol evaluation if:
your LDL cholesterol remains above target despite statins
your doctor has told you your cholesterol is difficult to control
you have coronary artery disease or prior stents
you have a strong family history of early heart disease
you have been told you may have familial hypercholesterolaemia
you cannot tolerate higher doses of statins
Dr Chan Po Fun regularly evaluates patients in these situations to determine whether treatment can be optimised further.
Why is my LDL still high despite statins?
There are several reasons why cholesterol levels may remain elevated even with appropriate statin therapy.
1. Very High Baseline LDL Cholesterol
Some patients start with extremely high LDL levels. Even with strong statins, the reduction may not be enough to reach target levels.
2. Genetic Cholesterol Conditions
Conditions such as familial hypercholesterolaemia (FH) cause the body to maintain high cholesterol levels due to inherited genetic factors. These patients often require combination therapy.
3. High Cardiovascular Risk
Patients with existing heart disease, such as previous heart attack, coronary artery disease, or stroke, require very aggressive LDL lowering. The recommended LDL targets in these patients are much lower than in the general population.
4. Statin Intolerance
Some individuals experience side effects with statins, such as muscle ache, which limit how much medication they can tolerate.
“When LDL remains above target, it often means the current treatment is not sufficient for the patient’s level of cardiovascular risk,” explains Dr Chan Po Fun.
Are You At Your Target LDL Level?
Many patients are unaware that LDL targets depend on cardiovascular risk.
Cardiovascular Risk | Recommended LDL Target |
Moderate risk | <2.6 mmol/L |
High risk | <1.8 mmol/L |
Very high risk | <1.4 mmol/L |
Patients with coronary artery disease, prior heart attack, stroke, or diabetes often require very aggressive LDL reduction.
If LDL remains above target despite treatment, further therapy may be necessary.
Does this apply to you?
If your LDL remains above these targets despite medication, or if you have never had your cardiovascular risk formally assessed, a specialist review can help clarify whether your current treatment is sufficient.
When Statins Aren't Enough: The Treatment Ladder
For patients who remain above their LDL target despite statin therapy, guidelines recommend a stepwise approach. Each step adds further LDL reduction.
Step 1 — Optimise the statin first
Before adding other therapies, it is worth confirming the statin has been optimised. Not all statins cause the same side effects in every patient. Switching to a different statin, or adjusting the dose or schedule, resolves issues in many cases. This step is often skipped too quickly.
Step 2 — Add ezetimibe
Ezetimibe is an oral tablet that reduces cholesterol absorption from the intestine, working through a completely different mechanism from statins. When added to a statin, it typically lowers LDL by a further 15–20%. It is generally well-tolerated and is the standard second step before considering injectable therapies.
Step 3 — PCSK9 inhibition (injectable therapy)
For patients who remain above target despite optimised statin plus ezetimibe, injectable PCSK9-targeting therapies are now guideline-supported options in Singapore.
There are two main types:
Monoclonal antibody PCSK9 inhibitors (evolocumab / Repatha, alirocumab / Praluent) These injections block a protein called PCSK9 that normally limits the liver's ability to clear LDL from the blood. By neutralising PCSK9, the liver can remove significantly more LDL. They are self-administered every 2–4 weeks and reduce LDL by approximately 50–60% on top of existing treatment.
siRNA therapy (inclisiran / Leqvio) This newer approach works upstream, rather than blocking PCSK9 after it is produced, it silences the gene responsible for producing PCSK9 in the first place. The LDL reduction is similar (~50%), but the dosing schedule is significantly more convenient: after two initial injections given three months apart, it is administered just once every six months. For patients requiring long-term, aggressive LDL lowering, this is one of the least burdensome treatment options available.
"These therapies are not appropriate for every patient, but for the right individual, particularly those with familial hypercholesterolaemia, established heart disease, or persistently high LDL despite maximal oral therapy — they can achieve LDL reductions that were previously very difficult to reach," says Dr Chan Po Fun.
The choice between these options depends on your cardiovascular risk profile, LDL level, insurance coverage, dosing preference, and individual circumstances.
Who May Benefit From Advanced Cholesterol Therapy?
You may benefit from further evaluation if:
Your LDL cholesterol remains above target despite statins
You have coronary artery disease
You have had a heart attack or stroke
You have familial hypercholesterolaemia
You cannot tolerate higher doses of statins
Your doctor has recommended more aggressive cholesterol lowering
A cardiologist can help determine whether combination therapy or advanced lipid treatments are appropriate.
Dr Chan Po Fun provides specialist assessment for patients requiring more advanced cholesterol management in Singapore.
How Cholesterol Treatment Is Personalised
Managing cholesterol is not simply about prescribing medication.
A proper evaluation with Dr Chan Po Fun often includes:
cardiovascular risk assessment
review of prior cholesterol results
assessment of statin tolerance
evaluation for genetic cholesterol disorders
imaging or testing for underlying coronary artery disease
Based on these factors, a personalised treatment plan can be developed to achieve optimal LDL reduction while minimising side effects.
The goal is to achieve optimal LDL reduction while minimising side effects.
In clinical practice, Dr Chan Po Fun focuses on patients whose LDL cholesterol remains above target despite standard treatment, and tailors therapy based on individual cardiovascular risk.
Elevated Lipoprotein(a) [Lp(a)]
Did you know? Approximately 1 in 5 people has elevated Lp(a), a genetically inherited lipid particle that significantly raises cardiovascular risk but is not included in a standard cholesterol panel. Most patients with elevated Lp(a) have never been tested.
Lipoprotein(a), often written as Lp(a) and pronounced "L-P-little-a", is a genetically inherited particle that is separate from LDL cholesterol but significantly increases cardiovascular risk when elevated.
Lp(a) is important for several reasons:
It is entirely determined by genetics — diet and lifestyle changes have virtually no effect on it
It is not included in a standard cholesterol panel — most patients have never been tested
Elevated Lp(a) can mean your true cardiovascular risk is higher than your LDL number suggests
It can help explain why some patients develop heart disease or have difficulty reaching LDL targets despite apparently good cholesterol control
Lp(a) affects approximately 1 in 5 people and is more commonly elevated in individuals of South Asian and African descent.
Who should be tested for Lp(a)?
Testing is particularly relevant if you have:
A strong family history of premature heart disease
LDL cholesterol that remains persistently elevated despite treatment
Had a heart attack or stroke at a younger-than-expected age
A family member with known elevated Lp(a)
Current guidelines recommend testing Lp(a) at least once in every adult's lifetime. If elevated, it changes how aggressively other risk factors, including LDL, should be managed.
"Lp(a) is one of the most underdiagnosed cardiovascular risk factors I see in clinical practice. Many patients with persistently high cardiovascular risk have never had it tested. It is a simple blood test that can meaningfully change how we manage their overall risk," says Dr Chan Po Fun.
Dedicated therapies targeting Lp(a) are currently in late-stage clinical trials globally, with several expected to become available in coming years. In the meantime, identifying elevated Lp(a) allows for more aggressive management of other modifiable risk factors.
When to Seek Specialist Evaluation
If your cholesterol remains elevated despite medication, further assessment may be helpful.
This is particularly important if you have:
existing heart disease
strong family history of heart disease
genetic cholesterol conditions
persistently elevated LDL levels
elevated Lp(a) levels
Early optimisation of cholesterol treatment can significantly reduce the long-term risk of heart attack and stroke.
About Dr Chan Po Fun
Dr Chan Po Fun is a consultant cardiologist in Singapore with a focused practice in lipid management, including complex cases of familial hypercholesterolaemia, statin intolerance, elevated Lp(a), and patients who have not reached LDL targets despite treatment.
She sees every patient personally throughout their care journey, from first assessment to long-term follow-up, with a clear focus on achieving the right LDL target for each individual's cardiovascular risk, not just a number that looks acceptable on a lab report.
Book a Consultation
If your LDL cholesterol remains high despite treatment, a specialist review can help clarify whether your current plan is sufficient, and what your options are.
A consultation can determine whether:
Your current treatment is sufficient
Additional therapy is needed
Advanced options such as PCSK9-inhibitors are appropriate
Consultations are available at Gleneagles Hospital and Mount Alvernia Hospital. No referral is required. Same- or next-day appointments are generally available.
FAQ
Why is my LDL still high despite taking statins?
There are several reasons. Your LDL target may be lower than you realise — patients with existing heart disease, diabetes, or prior cardiovascular events require LDL below 1.4 mmol/L, a level that statins alone often cannot achieve. Some patients also have a genetic condition called familial hypercholesterolaemia that limits how much statins can reduce LDL. And some patients cannot tolerate high enough statin doses due to muscle side effects. A specialist assessment can identify which applies to you and what the appropriate next step is.
What are PCSK9 inhibitors and how are they different from statins?
Statins work by reducing cholesterol production in the liver. PCSK9 inhibitors work differently — they block a protein that normally limits the liver's ability to clear LDL from the blood. By removing this limitation, the liver can remove significantly more LDL. They are injectable rather than oral, and can reduce LDL by 50–60% on top of statin therapy.
What is the difference between PCSK9 inhibitor antibodies (Evolocumab, Repatha) and siRNA therapy (Inclisiran, Leqvio)?
Monoclonal antibody PCSK9 inhibitors (such as evolocumab) neutralise PCSK9 after it has already been produced by the liver, and are given every 2–4 weeks. siRNA therapy (inclisiran) works earlier in the process — it prevents the liver from producing PCSK9 in the first place. The LDL reduction is similar, but siRNA therapy only needs to be given twice a year after the initial doses, making it significantly more convenient for long-term use.
What is Lp(a) and why does it matter?
Lipoprotein(a), or Lp(a), is a genetically inherited lipid particle that significantly raises cardiovascular risk. Unlike LDL cholesterol, it is not reduced by statins or lifestyle changes, and it is not included in a standard cholesterol test. Approximately 1 in 5 people has elevated Lp(a). If you have a strong family history of early heart disease, or LDL that remains persistently high despite treatment, testing for Lp(a) may meaningfully change how your overall risk is managed.
Can cholesterol injections replace statins?
In most cases, injectable therapies are used alongside statins to achieve additive LDL reduction — they work through different mechanisms, so the effects combine. In patients who genuinely cannot tolerate any statin due to side effects, they may be used as the primary cholesterol-lowering therapy, often combined with ezetimibe.
When should I see a cardiologist for high cholesterol?
Consider specialist evaluation if your LDL remains above your risk-appropriate target despite medication, if you have never had your cardiovascular risk formally assessed, if you have a strong family history of early heart disease, or if you have been told you may have familial hypercholesterolaemia or elevated Lp(a). Early optimisation of cholesterol treatment meaningfully reduces the long-term risk of heart attack and stroke.
Are these injectable therapies available in Singapore without a referral?
Yes. You can book directly with a cardiologist for a cholesterol assessment and treatment review without a GP referral.
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