Peptides Are Having a Moment — Here's What NPs Need to Know Right Now

 

NP CHRONICLES Clinical Awareness Brief

Peptides Are Having a Moment — Here's What NPs Need to Know Right Now

An FDA advisory panel is reconsidering compounding rules for BPC-157 and six other peptides, even as the basic science press stays deeply skeptical of the mail-order peptide trade.

If your patients haven't asked you about peptides yet, they probably will soon. This week the FDA convened a two-day advisory panel to reconsider whether compounding pharmacies should be allowed to prepare seven specific peptides — including BPC-157, a favorite of biohacking and "research use only" marketplaces — under prescription and physician oversight. The timing lands right on top of two other useful reads: a widely circulated science-blog takedown of the mail-order peptide trade, and a comprehensive academic review of legitimate, FDA-approved peptide therapeutics. Read together, the three pieces sketch out exactly where the clinical conversation with patients needs to go.

Two Very Different Worlds Called "Peptides"

Part of what makes this topic slippery in the exam room is that "peptide" means two different things depending on who is saying it. Chemically, a peptide is simply a short chain of amino acids — a category broad enough to include everything from digestive breakdown products to insulin itself. Clinically and commercially, "Peptides" (capital P, as science writer Derek Lowe puts it) has become shorthand for a specific class of injectable, mail-order compounds marketed for muscle building, fat loss, hair regrowth, tissue repair, and anti-aging — most of them sold with little to no human trial data behind them.

There are more than 80 FDA-approved peptide drugs on the market today, spanning diabetes care (the GLP-1 receptor agonists), oncology, cardiovascular disease, and antimicrobial therapy. Those drugs went through the same design-synthesis-modification-trial pipeline as any other pharmaceutical. The peptides driving patient questions in your clinic right now — BPC-157, various growth-hormone-releasing peptides, and others sold through gray-market suppliers — have not.

 

What's Actually on the Table at the FDA This Week

The panel isn't deciding whether to approve BPC-157 or its peers as drugs. It's deciding whether compounding pharmacies can legally prepare them under a prescription, for a specific diagnosis, with physician oversight — a narrower and more clinically supervised pathway than the current gray market, but still well short of full FDA approval with its accompanying efficacy and manufacturing standards.

●      BPC-157 is marketed for tissue and injury healing. As one physician noted in a recent STAT piece, it has been studied in roughly a dozen human subjects — compare that to the six-figure trial populations behind statins or GLP-1 drugs.

●      The Biden-era FDA had already added nearly 20 peptides to the list of substances compounding pharmacies should not prepare, citing insufficient safety data.

●      Most of the current advisory panel and agency staff involved in that 2020s-era decision are no longer in their roles, and HHS Secretary Robert F. Kennedy Jr. has publicly described himself as a supporter of these unapproved therapies.

●      The outcome will not constitute FDA approval of any of these peptides as drugs — it would only change who is legally allowed to compound them and under what supervision.

Why the Science Press Is Sounding the Alarm

Lowe's post (published on his long-running chemistry blog) walks through the mechanistic case for caution, and it's worth internalizing the framework even if you never mention his name to a patient:

●      Bioactivity is not the same as a known safety profile. Short peptides can have dramatic biological effects, but the field is still discovering off-target activity even for extremely well-studied hormones like insulin.

●      Reactivating growth pathways carries a generic cancer-risk concern. Growth hormone axis peptides in particular risk recreating the physiology of acromegaly — bone overgrowth, joint pain, hypertension, and type 2 diabetes — when taken outside physiologic feedback control.

●      Sourcing is a black box. Patients ordering from unregulated suppliers have no way to verify purity, concentration, or degradation, and no regulatory body compelling the supplier to care.

●      The appeal is often ideological as much as clinical — a "do my own research," anti-regulatory framing that can lead patients to discontinue well-evidenced therapies (statins, in the STAT anecdote) in favor of a compound studied in a literal handful of people.

AMBER FLAG — Don't Let the GLP-1 Comparison Do the Wrong Work Patients will sometimes reason, "GLP-1 drugs are peptides too, and those turned out great — so why not this one?" It's worth naming that logical leap directly. Semaglutide and liraglutide reached the market only after extensive sequence modification, half-life extension, and trial programs involving well over 100,000 patients combined. A gray-market peptide with a study population in the dozens has none of that behind it. Same molecular category, entirely different evidence base.

Case From Practice

"My Trainer Said BPC-157 Would Heal My Rotator Cuff Faster" A 34-year-old patient with a partial supraspinatus tear, already referred to physical therapy, asks whether you can prescribe or approve a BPC-157 regimen he found through an online fitness coach. He has done "his own research" and read that it's "basically a natural healing peptide." This is a good opening for motivational, non-adversarial patient education rather than a flat refusal-and-move-on. Points worth hitting: ●      Validate the goal (faster, better healing) before addressing the method — the desire to heal well is reasonable even if the chosen tool isn't. ●      Name the evidence gap plainly: BPC-157 has essentially no controlled human trial data for musculoskeletal healing, and no established dosing, purity standard, or long-term safety profile. ●      Ask where he'd be sourcing it — most patients haven't considered that an unregulated supplier has no incentive to guarantee what's actually in the vial. ●      Redirect to what does have evidence for tendon/rotator cuff recovery: structured PT progression, load management, and, where appropriate, evidence-based adjuncts you can actually document and monitor. ●      Document the conversation. If the patient proceeds through a gray-market source anyway, you want a clear record that risks were discussed.

Clinical Bottom Line

●      Legitimate, FDA-approved peptide drugs (GLP-1 receptor agonists, insulin analogues, GnRH-derived agents, ziconotide, etc.) are a mature, well-evidenced drug class — don't let "peptide" become a red-flag word in your own head. ●      Gray-market "research peptides" like BPC-157 are a separate category with minimal human data, unverified sourcing, and real theoretical risk (growth-pathway activation, cancer risk, contamination). ●      The FDA's current review is about compounding access under prescription, not drug approval — expect this to change the conversation with patients even if it doesn't change the evidence base. ●      Anticipate the question before the patient asks it. A brief, non-judgmental script ("tell me what you've read, here's what we actually know") keeps patients from sourcing these compounds entirely outside medical supervision.

Board Prep: Know Your Peptide Drug Classes

Certification exams love peptide pharmacology because it cuts across endocrine, cardiovascular, GI, and oncology content. A few high-yield associations worth drilling:

●      GLP-1 receptor agonists (exenatide, liraglutide, semaglutide, dulaglutide) — T2DM and weight management; GI side effects; class-wide caution in personal/family history of medullary thyroid carcinoma.

●      GnRH agonists/antagonists (leuprolide, degarelix) — hormone-responsive prostate cancer, endometriosis, precocious puberty; agonists cause an initial testosterone flare, antagonists do not.

●      Somatostatin analogues (octreotide) — acromegaly, carcinoid symptom control, variceal bleeding adjunct.

●      GLP-2 analogue (teduglutide) — short bowel syndrome; distinguish mechanism from GLP-1 on exam distractor questions.

●      N-type calcium channel blocker (ziconotide) — intrathecal use only for severe chronic pain; derived from cone snail venom, a good "where do peptide drugs come from" trivia point.

●      Natriuretic peptide analogue (nesiritide) — acutely decompensated heart failure; limited by hypotension risk and modest specificity.

References

Lowe, D. "Peptides. Where to Begin?" In the Pipeline (Science Translational Medicine blog), April 6, 2026.

Wang, L., Wang, N., Zhang, W., et al. "Therapeutic peptides: current applications and future directions." Signal Transduction and Targeted Therapy 7, 48 (2022). https://doi.org/10.1038/s41392-022-00904-4

Breen, K., Yamaguchi, A. "FDA panel reviewing some peptides to consider loosening regulations for unapproved therapies." CBS News, July 23, 2026.

NP Chronicles — Clinical education for NP students and new graduates since 2012.

New ACC Guidance on Obesity and Cardiovascular Disease: What Every NP Needs to Know

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If you're a nurse practitioner in primary care, family practice, or cardiology, you already know that the obesity conversation has fundamentally changed. We're no longer in the era of "eat less, move more" as the sole clinical recommendation. The American College of Cardiology dropped two major guidance documents in August 2025 that every NP managing cardiovascular risk needs to have on their radar — and if you missed them, consider this your clinical catch-up.

Let's break down what matters for your practice.

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Two Documents, One Clear Message

The ACC released a Concise Clinical Guidance (CCG) on the medical management of obesity and a Scientific Statement focused specifically on treating obesity in adults with heart failure. Both documents signal a seismic shift in how we should be thinking about weight management as a core component of cardiovascular care — not a side conversation.

The CCG was led by Olivia Gilbert, MD, MSc, FACC, and Martha Gulati, MD, MS, FACC. The Scientific Statement on heart failure and obesity was led by Michelle M. Kittleson, MD, PhD, FACC.

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The Big Takeaway: Obesity Is Multifactorial — Treat It That Way

The CCG lays out what many of us have observed clinically but haven't always had guideline-level backing to support: the causes of obesity are multiple. We're talking genetics, neurological and psychological factors, nutrient and hormonal imbalances, environmental influences, social determinants of health, and even medical conditions and medications themselves.

For NPs, this is validation. When your patient tells you they've "tried everything," the science now formally acknowledges that willpower isn't the issue. The pathophysiology is complex, and our treatment approach needs to reflect that complexity.

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Pharmacotherapy: No More "Try and Fail"

Here's the line every NP should commit to memory from this guidance: patients should not be required to "try and fail" lifestyle changes before initiating pharmacotherapy. That said, lifestyle interventions should always be offered alongside obesity medications — not as a prerequisite, but as a complement.

This is a critical distinction for our practice. How many times have we felt pressure (from insurance companies, from institutional culture, from our own training) to exhaust lifestyle modifications before considering medication? This guidance explicitly says that's not the standard anymore.

What's Working: The Pharmacologic Landscape

Among FDA-approved medications, the guidance highlights two agents with the strongest efficacy data:

• Semaglutide (GLP-1 receptor agonist)
• Tirzepatide (GLP-1/GIP receptor agonist)

Clinical trial data and real-world observational evidence suggest slightly greater weight loss with tirzepatide. However — and this is the reality check for primary care NPs — insurance coverage, availability, and affordability are likely to dictate agent selection more than head-to-head efficacy data.

Sound familiar? Welcome to every prior authorization conversation you've ever had.

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The Cardiovascular Connection: Why This Matters Beyond the Scale

The guidance makes the cardiovascular argument crystal clear. Obesity-related CV disease risks include:

• Sleep apnea
• Dyslipidemia
• Chronic inflammation
• Hypertension
• Type 2 diabetes and insulin resistance
• Atrial fibrillation
• Heart failure (both HFpEF and HFrEF)
• ASCVD
• VTE/PE
• Valvular heart disease
• Sudden cardiac death

The document notes that unhealthy weight has been linked to more than 60 conditions. And the cardiovascular risk reduction data is compelling — clinical evidence supports these medications leading to a reduction in major adverse cardiovascular events (MACE), including cardiovascular death, MI, and stroke, particularly in individuals with type 2 diabetes and elevated CV risk.

For NPs managing patients with multiple comorbidities, this reframes the conversation. Weight management isn't cosmetic. It's cardiovascular risk reduction.

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Obesity in Heart Failure: A New Frontier

The Scientific Statement specifically addresses obesity management in adults with heart failure, with particular focus on Stage 2 HFpEF. This is the first in a new series of clinical guidance from the ACC targeting areas where evidence is evolving.

Here's what the central illustration from the statement tells us about weight loss strategies in HF:

Behavioral Changes (Diet and Exercise)

• 5%–10% weight loss achievable
• Exercise and caloric restriction have additive effects
• Weight loss is difficult to sustain long-term with significant regain
• Limited data specifically in HF, but successful weight loss is associated with improved functional status and reduced symptom burden in HFpEF

Anti-Obesity Medications

• 10%–20% weight loss achievable
• Weight regain occurs with cessation of medications
• Semaglutide: Significant improvement in functional status and symptom burden in HFpEF; reduced rates of MACE and HF hospitalization
• Tirzepatide: Additional benefit of reduced risk for CV death or HF events in HFpEF (though low event rates limit conclusive assessment)

Metabolic and Bariatric Surgery

• 10%–30% weight loss, often sustained over years
• No randomized data specifically in HF populations
• Observational data suggests reduced risk of incident HF and decreased rates of HF hospitalization and inpatient mortality
• Important caveat: individuals with HF, especially HFrEF, may have higher rates of complications with surgery

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Six Key Clinical Decision-Making Areas for NPs

The CCG outlines six areas that should shape your clinical approach:

1. Rationale and Eligibility Pharmacotherapy balances effectiveness and invasiveness. Eligibility may be determined by BMI thresholds or other risk indicators. These therapies can be adjusted to minimize adverse effects and personalize care.

2. Pharmacological Options Know your agents, know the data, and know the insurance landscape. Semaglutide and tirzepatide lead in efficacy, but practical access drives real-world prescribing decisions.

3. Impact on Cardiovascular Risk The MACE reduction data is the strongest argument you have when justifying treatment to insurers, patients, and colleagues.

4. Multidisciplinary Care Approaches Team-based care is emphasized — assess modifiable risk factors, identify comorbidities, and tailor strategies. NPs are perfectly positioned to quarterback this.

5. Reducing Bias and Improving Patient Experience Use person-first language. Create welcoming clinical environments. Address weight stigma directly. Validate the lifelong journey patients experience with this chronic disease. This isn't a soft recommendation — it's guideline-level.

6. Access Considerations Insurance coverage remains the single biggest barrier. Strategies include identifying patients most likely to benefit, closely monitoring treatment outcomes, and price negotiations.

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What This Means for Your NP Practice

Here's my bottom line for fellow NPs:

Start the conversation. If you're managing a patient's hypertension, diabetes, dyslipidemia, or heart failure, and they have obesity — you now have ACC-level guidance supporting pharmacologic intervention as part of their cardiovascular treatment plan. Not instead of lifestyle changes. Alongside them.

Document the cardiovascular indication. When you're writing that prior authorization, frame it as cardiovascular risk reduction. The MACE data is your best friend.

Don't wait for cardiology to initiate. As the CCG states, weight management by the cardiovascular community — and I'd argue the primary care community even more so — needs to be embraced. NPs in primary care are often the first and most consistent point of contact. We are the cardiovascular community.

Stay current on access pathways. The insurance landscape for GLP-1 receptor agonists and GIP/GLP-1 receptor agonists is evolving rapidly. Know your formularies, know your PA requirements, and know the manufacturer assistance programs.

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Clinical Pearl

When documenting obesity in your patients' charts, code it as the chronic disease it is. Use the cardiovascular risk language from this guidance. Your documentation should reflect that you're treating obesity not as a lifestyle choice, but as a multifactorial chronic disease with direct cardiovascular consequences. This matters for your patients' care continuity, insurance approvals, and outcomes tracking.

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Resources

• ACC Concise Clinical Guidance on Medical Weight Management — published in JACC, August 2025
• ACC Scientific Statement: Obesity in Adults with Heart Failure — published in JACC, August 2025
• CardioSmart.org/Weight — patient education infographics and materials

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What changes are you seeing in your practice around obesity management? Are your patients getting access to these medications? Drop a comment below — I'd love to hear from NPs in the trenches.

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Valerie Watters-Burke, DNSc, MSN, MBA, FNP-BC, GNP-BC, PPCNP-BC NP 

 

Clinical Updates · Cardiology

The 2026 ACC/AHA Dyslipidemia Guidelines:
Everything Primary Care NPs Need to Know Right Now

A comprehensive clinical breakdown of the most significant cholesterol guideline update in nearly a decade.

PublishedApril 2026· NP Chronicles ·12-minute read· Updated from the 2018 ACC/AHA Guideline

The 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia dropped this spring — and if you manage patients with cardiovascular risk in primary care, this one is going to change your practice. Here's what you need to know, translated for the clinic floor.

Whether you're seeing a 45-year-old with a new diabetes diagnosis, a 58-year-old post-MI patient not at LDL goal, or a young woman with a family history of premature heart disease, the 2026 guidelines give us clearer targets, updated risk tools, and several entirely new recommendations that simply didn't exist before. Let's break it down.

📋 Quick Context

This guideline is co-authored by 11 major professional organizations and replaces the 2018 ACC/AHA Cholesterol Guideline. It was approved in October–December 2025 and published in the Journal of the American College of Cardiology and Circulation. The evidence review covers literature through April 2025.

01 — Risk AssessmentThe PREVENT Equations Replace the Pooled Cohort Equations

This is the first and most operationally significant change you'll encounter. The old Pooled Cohort Equations (PCE) are out. The new PREVENT-ASCVD equations are now the standard for estimating 10-year cardiovascular risk in adults aged 30–79 without established ASCVD or subclinical atherosclerosis, with LDL-C between 70 and 189 mg/dL.

The PREVENT model is more contemporary, more inclusive, and incorporates additional cardiometabolic factors. Risk is now categorized into four tiers:

<3%Low Risk

3–<5%Borderline Risk

5–<10%Intermediate Risk

≥10%High Risk

The guideline introduces a helpful framework called the "CPR" Model for primary prevention decision-making:

• Calculate 10-year ASCVD risk using PREVENT-ASCVD equations
• Personalize estimated risk by considering factors not included in the equations (risk enhancers, reproductive history, social determinants)
• Reclassify with selective use of CAC scoring and reassess treatment recommendations

🩺 NP Clinical Pearl

The PREVENT calculator is available free at tools.acc.org. Make it a habit to update this with every patient over 30 at their annual wellness visit. The new model also incorporates 30-year risk for patients aged 30–59, which is a meaningful addition for young patients who may feel "too young" to worry about cholesterol.

02 — Lab TestingNew Guidance on What to Measure (and Why It Matters)

Lp(a) — Now Recommended for Everyone, Once

This is a landmark change. For the first time, the guidelines give a Class I (COR 1) recommendation that all adults have lipoprotein(a) [Lp(a)] measured at least once in their lifetime for ASCVD risk assessment. Previously, this was reserved for select high-risk individuals.

⚠️ Why This Matters

Lp(a) ≥125 nmol/L (≥50 mg/dL) confers approximately 1.4× increased ASCVD risk. Levels ≥250 nmol/L (≥100 mg/dL) are associated with a ≥2-fold higher risk. Elevated Lp(a) should prompt more intensified LDL-C lowering and rigorous management of all other modifiable risk factors. Lp(a)-specific therapies are in trials — knowing your patient's level now matters.

ApoB — New Supporting Role in Monitoring

A new COR 2a recommendation supports measuring apolipoprotein B (apoB) in adults on lipid-lowering therapy — particularly those with ASCVD, cardiovascular-kidney-metabolic (CKM) syndrome, type 2 diabetes, and/or elevated triglycerides — once LDL-C and non-HDL-C goals are achieved. ApoB helps identify residual lipoprotein-related risk that a standard lipid panel may underestimate, especially in patients with elevated TG or low achieved LDL-C (<70 mg/dL).

Better LDL-C Calculation

The old Friedewald equation for calculating LDL-C is no longer preferred. The guidelines now recommend either the Martin/Hopkins equation or the Sampson/NIH equation as standard — both are significantly more accurate, especially at low LDL-C levels. Most modern lab systems and electronic health records have already transitioned to these methods, but verify with your lab.

03 — Primary PreventionTreat Earlier, Treat Smarter, Set Goals

The 2026 guidelines make a major philosophical shift: LDL-C and non-HDL-C treatment goals are back. The 2018 guideline moved away from specific targets toward percentage reductions. The 2026 guideline brings both — percentage reductions and specific numeric goals — depending on risk category.

Risk Category	Statin Intensity	LDL-C Goal	Non-HDL-C Goal
Low (<3%), LDL-C <160	Lifestyle counseling only	—	—
Low (<3%), LDL-C 160–189 or 30-yr risk ≥10%	Moderate-intensity (COR 2a)	<100 mg/dL	<130 mg/dL
Borderline (3–<5%)	Moderate-intensity if initiated (COR 2a)	<100 mg/dL	<130 mg/dL
Intermediate (5–<10%)	At least moderate; high if upper range (COR 1)	<100 mg/dL	<130 mg/dL
High (≥10%)	High-intensity (COR 1)	<70 mg/dL	<100 mg/dL

💡 Key Shift for NPs

Borderline-risk patients (3–<5%) can now be treated — this is an upgrade from COR 2b (may be considered) to COR 2a (is reasonable). For intermediate-risk patients, statin initiation is a Class I recommendation. And for the first time, specific LDL-C target goals accompany statin intensity recommendations at every risk tier.

Reproductive Risk Markers Are Now Part of Risk Assessment

New for 2026: a COR 2a recommendation supports considering reproductive risk markers — including early menopause (<45 years), gestational hypertension, preeclampsia, gestational diabetes, and preterm delivery — when personalizing ASCVD risk assessment for primary prevention. These adverse pregnancy outcomes are now recognized as independent cardiovascular risk enhancers that should prompt earlier consideration of lipid-lowering therapy.

04 — CAC ScoringCoronary Artery Calcium Gets Expanded, Actionable Guidance

Coronary artery calcium (CAC) scoring receives its most detailed and actionable guidance to date. It's no longer just a tiebreaker when statin use is uncertain — it now generates its own treatment targets based on score severity.

CAC Score	Recommendation	LDL-C Goal
0 AU	Defer therapy; reassess in 3–7 years (COR 2a, if no high-risk conditions)	—
1–99 AU, <75th percentile	Moderate-intensity statin (COR 2a)	<100 mg/dL
≥100 AU or ≥75th percentile	Initiate LLT (COR 1)	<70 mg/dL
≥300–999 AU	High-intensity statin; intensify to <55 mg/dL if needed (COR 1/2a)	<70 → <55 mg/dL
≥1000 AU	Treat as very high risk (COR 1)	<55 mg/dL

Importantly, incidental CAC found on non-cardiac CT scans (pulmonary emboli workups, chest CTs, etc.) should now be factored into treatment decisions. AI-based algorithms are specifically mentioned as valid tools for detecting coronary atherosclerosis on noncardiac imaging — a forward-thinking addition that reflects real-world practice.

05 — Secondary PreventionLower Goals, More Tools

The 2026 guidelines take a notably more aggressive approach to secondary prevention. Most patients with established ASCVD should now be treated to an LDL-C goal of <55 mg/dL — a target that will require nonstatin therapy in many patients.

🔴 High Risk vs. Very High Risk

The 2026 guideline distinguishes between ASCVD patients who are "not at very high risk" (LDL goal <70 mg/dL and non-HDL <100 mg/dL) and those "at very high risk" (recent ACS, multiple ASCVD events, ASCVD + diabetes/CKD/HeFH — LDL goal <55 mg/dL and non-HDL <85 mg/dL). In practice, most of your established ASCVD patients will qualify for the <55 mg/dL target.

The Nonstatin Toolkit — Now with More Options

When maximally tolerated statin therapy isn't getting patients to goal, the guideline now explicitly supports a stepwise approach using:

Agent	Mechanism	Use Case / Strength
Ezetimibe	NPC1L1 inhibitor	First add-on; oral, well-tolerated (COR 1/2a)
PCSK9 mAbs (evolocumab, alirocumab)	PCSK9 inhibition	Robust LDL lowering 50–60%; injectable q2-4wk (COR 2a)
Bempedoic acid	ATP-citrate lyase inhibitor	Oral option for statin-intolerant patients; new expanded role (COR 2a)
Inclisiran	siRNA targeting PCSK9	New — twice-yearly injection; option for those unable to tolerate PCSK9 mAbs or preferring infrequent dosing (COR 2a)

Inclisiran is the newest addition to the guideline-endorsed toolkit. For patients who struggle with injection frequency or who cannot access or tolerate evolocumab/alirocumab, inclisiran's twice-yearly dosing offers a compelling alternative.

06 — Special PopulationsDiabetes, FH, CKD, HIV, and Cancer Survivors

Diabetes (Ages 40–75)

The foundational recommendation is unchanged — moderate-intensity statin therapy is COR 1 for all adults 40–75 with diabetes without established ASCVD. What's new: explicit LDL-C and non-HDL-C goals are now attached. The target is LDL-C <100 mg/dL and non-HDL-C <130 mg/dL. For those with multiple ASCVD risk factors, high-intensity statin therapy targeting LDL-C <70 mg/dL and non-HDL-C <100 mg/dL is COR 2a.

Familial Hypercholesterolemia (FH)

Several important updates for FH management:

• Standard risk calculators should not be used in HeFH (COR 3 — these patients are always at elevated risk regardless of what the calculator says)
• Genetic testing for pathogenic FH variants is reasonable in adults with LDL-C ≥190 mg/dL without secondary causes (COR 2a)
• For HeFH without ASCVD: goal LDL-C <70 mg/dL; with ASCVD: goal <55 mg/dL
• Homozygous FH (HoFH): evinacumab added as an option when LDL-C remains ≥100 mg/dL on max therapy including PCSK9 mAbs (COR 2b)

CKD Stage 3 or Higher with ASCVD

New COR 1 recommendation: these patients should receive high-intensity statin therapy ± ezetimibe ± PCSK9 mAb to achieve ≥50% LDL-C reduction with a goal of <55 mg/dL. This aligns CKD+ASCVD patients with the very high-risk secondary prevention tier.

People Living with HIV

A brand-new COR 1 recommendation: adults aged 40–75 living with HIV on stable antiretroviral therapy should receive statin therapy to reduce first ASCVD event risk and slow coronary atherosclerosis progression. This is a particularly important addition given the cardiovascular risk profile of this population.

Cancer Survivors

New COR 1: adult cancer survivors with life expectancy ≥2 years who otherwise qualify for lipid-lowering therapy should be treated the same as patients without cancer history. Don't withhold guideline-indicated therapy due to oncologic history alone.

07 — TriglyceridesUpdated Guidance Including New Therapies

Persistently elevated triglycerides deserve more attention under the 2026 framework. Key updates:

TG Management Highlights

TG 150–999 mg/dL with ASCVD: If LDL-C and non-HDL-C are above goal, intensify LDL-C lowering therapy first (COR 1).

TG ≥500 mg/dL: Refer to a registered dietitian nutritionist (RDN) for pancreatitis risk reduction.

TG 150–999 mg/dL + CKM syndrome features: RDN referral is also recommended.

Familial chylomicronemia syndrome (TG ≥1000 mg/dL): Olezarsen (an apoC3 inhibitor) is now COR 1 — the first guideline endorsement of this novel mechanism for pancreatitis prevention.

For adults 40–75 without ASCVD or diabetes but with persistently elevated TG (150–499 mg/dL), the guideline now recommends using PREVENT equations to estimate ASCVD risk and have a benefit-risk discussion about statin therapy — a new, proactive approach to this often-undertreated group.

08 — What's OutDietary Supplements — A Clear "No"

🚫 COR 3 — Do Not Recommend

For the first time, the guidelines include a Class III recommendation against dietary supplements for lowering LDL-C or triglycerides. This includes fish oil (for LDL/TG in non-pancreatitis settings), red yeast rice, berberine, plant sterols marketed as supplements, and other nutraceuticals. The evidence for meaningful cardiovascular benefit is limited and inconsistent. When patients ask about supplements, you now have guideline-level support for redirecting that conversation toward proven therapies and lifestyle changes.

Lower longer, start earlier, and treat to goal — the 2026 guidelines make it clear that cumulative lipoprotein exposure over a lifetime is what drives atherosclerosis, and NPs are on the front lines of changing that trajectory.

09 — For Your Practice10 High-Yield Takeaways to Implement Now

1

Order an Lp(a) on every adult — once

This is now a Class I recommendation. Add it to your next comprehensive lipid panel for any patient who hasn't had one. It's a one-time test with lifelong relevance.

2

Switch your risk calculator to PREVENT-ASCVD

The PCE is no longer the recommended tool. Bookmark the ACC PREVENT calculator and use it for every primary prevention conversation.

3

Know your patients' non-HDL-C goals

Non-HDL-C targets are now paired with every LDL-C goal. Non-HDL-C = total cholesterol − HDL-C; goals are 30 mg/dL higher than the corresponding LDL-C goal at each tier.

4

Ask about adverse pregnancy outcomes in all women

Preeclampsia, gestational diabetes, preterm delivery, and early menopause are now formal risk enhancers. Add these to your cardiovascular history intake questions.

5

Don't stop at statin intolerance — use bempedoic acid

Bempedoic acid has an expanded role in 2026, including as an add-on for very high-risk secondary prevention patients. It's a valuable oral option when statins aren't tolerated.

6

Treat your cancer survivors to the same LDL targets

If a cancer survivor with prior MI needs a high-intensity statin and their oncologist hasn't initiated one, that's a gap you can close in primary care.

7

Consider inclisiran for PCSK9-intolerant or access-challenged patients

Twice-yearly injection given in-office removes the adherence barrier of self-injection. It's now guideline-endorsed for very high-risk patients who can't access or tolerate the mAbs.

8

Start statins in your HIV-positive patients 40–75

This is now a Class I recommendation. Review your HIV-positive panel and assess who is and isn't on statin therapy — drug interactions with antiretrovirals matter, but pravastatin and rosuvastatin are generally safer choices.

9

Don't recommend dietary supplements for cholesterol

The guideline explicitly says no (Class III). Armed with this, you can redirect patients toward dietary patterns (Mediterranean, DASH, plant-forward) and proven pharmacotherapy.

10

Use incidental CAC findings on any CT — they count now

If a chest CT PE protocol mentions coronary calcification, that's clinically actionable information for lipid management. Review those radiology reports actively.

Final ThoughtsFrom One NP to Another

The 2026 dyslipidemia guidelines are the most comprehensive, practically actionable cholesterol guidelines we've had in years. They give us clearer targets, better risk tools, and more validated therapies — including several that are genuinely new to this iteration.

What stands out most to me is the underlying philosophy: treat earlier, treat to goal, and individualize based on the whole patient — including their reproductive history, comorbidities, imaging, and genetic context. The days of "start a statin and recheck in a year" without a specific target in mind are over.

For those of us in primary care and telehealth, these guidelines validate what many of us have already been doing intuitively — and give us the evidence-based language to advocate for more aggressive therapy when our patients need it.

📄 Full Guideline Reference

Blumenthal RS, Morris PB, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia. J Am Coll Cardiol. 2026. DOI: 10.1016/j.jacc.2025.11.016. Available at acc.org and professional.heart.org.