In this article in the Drug and Therapeutics Bulletin (DTB), the authors discuss whether colesevelam (Cholestagel®), a bile acid sequestrant, has a useful role in the management of primary hypercholesterolaemia. It is licensed for use either as monotherapy when statins are not tolerated or considered inappropriate, or as an adjunct to statin therapy in patients who are not adequately controlled on a statin alone. The authors conclude that they could not recommend its use for the following reasons:

• The reduction of LDL-cholesterol on monotherapy is substantially less than that with statins alone (even when they are taken at suboptimal doses).
• Published studies have not assessed clinical outcomes and there is no longer-term safety data.
• Like other bile acid sequestrants, the drug can cause GI side effects and may aggravate hypertriglyceridaemia.
• There is a need to take a large number of colesevelam tablets daily which may compromise adherence.