Lipoprotein apheresis: still needed in many patients, or soon a historical practice?

Abstract

Lipoprotein apheresis (LA) has long been used as an ultima ratio therapy for patients with extreme lipid-driven cardiovascular risk. One perspective maintains that, despite major advances in lipid-lowering pharmacology and the emergence of gene-silencing therapies, LA remains indispensable for selected patients with homozygous familial hypercholesterolemia (HoFH), severe hypercholesterolemia refractory to maximal therapy, and isolated lipoprotein(a) [Lp(a)]–mediated progressive cardiovascular disease. An opposing view argues that modern and emerging pharmacological agents—PCSK9 inhibitors, inclisiran, bempedoic acid, evinacumab, and targeted Lp(a)-lowering antisense and small interfering RNA (siRNA) agents—have already rendered LA obsolete in almost all patients, with its remaining niche closing rapidly as outcome data accumulate. This combined manuscript juxtaposes the two positions in a streamlined form and concludes with a balanced conclusion of the future role of LA.