BACKGROUND: Despite the availability of effective LDL cholesterol (LDL-C)-lowering drugs, only a minority of patients achieves the guideline-recommended treatment targets. This analysis describes treatment pathways of lipid-lowering therapy (LLT) in Germany. METHODS: Health claims data were used to identify patients at high or very-high cardiovascular risk who received a LLT prescription 2016-2022. Treatment pathways and the time to switch or discontinue LLT were analysed for statins, ezetimibe, bempedoic acid (BA), and PCSK9 inhibitors (PCSK9i). RESULTS: Out of 3,487,827 insured persons, 247,529 met the inclusion criteria. The most frequent first-line LLT were statins in 96.3%. Ezetimibe, BA, and PCSK9i were first-line LLT in only 0.9%, 0.061%, and 0.046%, respectively. Only few patients experienced a change in their treatment regimen following LLT initiation. Prescriptions of BA and PCSK9i were mainly second-, third-, or fourth-line add-on treatment. Termination of treatment with BA and PCSK9i was less frequent compared to statins and ezetimibe. The median time to treatment discontinuation was 1.45, 1.04, 0.60, and 2.45 years for statins, ezetimibe, BA, and PCSK9i, respectively, and the median time to switch therapy was 4.81 and 4.87 years for ezetimibe and PCSK9i, respectively (median not reached for statins and BA). CONCLUSIONS: Changes in LLT were only observed in a minority of patients. BA and PCSK9i were switched more frequently than statins and ezetimibe. BA was discontinued earlier, and PCSK9i later than the other agents. Continued efforts to maintain long-term adherence and overcome therapeutic inertia are needed to realise the potential of available LLT with proven cardiovascular benefit.