ApoB Lowering Protocol
Tiered pharmacologic approach to drive ApoB well below 60 mg/dL, starting with preferred statins and escalating to alternatives based on tolerance and phenotype.
Assembled by Cited from Peter Attia's recorded recommendations across multiple sources. It is not an ordered program and was not created or endorsed by them — it's our grouping of what they've said on the record.
Components
7-
In a protocol
Attia prefers measuring ApoB over LDL cholesterol because it captures total atherogenic lipoprotein concentration in one number.
“we have one single number that captures the total concentration of ApoB
TP▶ 32:30DosageAim to keep ApoB below 60 mg/dL (~5th percentile)CaveatsMany US physicians don't routinely order ApoB; patient may need to requestCertaintyexplicitstrong endorsementMeasure and target ApoB <60 mg/dL -
In a protocol
Attia's preferred starting statin for ApoB lowering, along with pravastatin.
“I like to start with Razuvastatin or Pravastatin
TP▶ 38:00Caveats~5% of patients have intractable muscle soreness with statinsCertaintyexplicitrecommendationPreferred first-line statin -
In a protocol Alternative
Preferred starting statin alongside rosuvastatin for lipid lowering.
“I like to start with Razuvastatin or Pravastatin
TP▶ 38:00CertaintyexplicitrecommendationPreferred first-line statin alongside rosuvastatin -
In a protocol Alternative
Second-line statin choice after rosuvastatin/pravastatin if tolerance is an issue.
“move to Pitavastatin or Livalo
TP▶ 38:20CertaintyexplicitrecommendationSecond-line statin if first-line not tolerated -
In a protocol Alternative
Used in hypersynthesizers who can't tolerate statins for lipid lowering.
“If they're a hypersynthesizer but can't respond to statins, we use mapendoic acid
TP▶ 39:00CertaintyexplicitrecommendationFor statin-intolerant hypersynthesizers -
In a protocol
Attia personally combines a PCSK9 inhibitor with a statin to dramatically lower ApoB.
“I take a PCSK9 inhibitor and I take a statin
TP▶ 37:50Certaintypersonal onlypersonal useAttia personally combines PCSK9i with a statin for maximal ApoB reduction
How this protocol has evolved
Attia is now far more aggressive — treat early (late 30s/early 40s), drive ApoB much lower (<60, ideally 20-40 range), and uses a structured rotation through statin and non-statin options based on patient phenotype/tolerance.