From the Guidelines
For this patient with suboptimal lipid control despite being on atorvastatin 40 mg, I recommend adding ezetimibe 10 mg daily to the current atorvastatin 40 mg, as the patient's LDL of 143 mg/dL and non-HDL of 176 mg/dL remain significantly above target levels, indicating inadequate response to the current therapy. The patient's lipid profile, with an LDL of 143 mg/dL, suggests that they may be at high risk for atherosclerotic cardiovascular disease (ASCVD) events, and according to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol, adding a non-statin to statin therapy is reasonable in patients with very high-risk ASCVD or those who have not achieved adequate LDL reduction on statin therapy alone 1. Before making medication changes, it's essential to assess medication adherence, diet, exercise habits, and possible secondary causes of dyslipidemia such as hypothyroidism or poorly controlled diabetes. Lifestyle modifications should be reinforced, including:
- A Mediterranean or DASH diet
- Regular physical activity
- Weight management if needed
- Limiting alcohol intake The rationale for intensifying therapy is that this patient likely has high or very high cardiovascular risk given the persistent dyslipidemia despite moderate-to-high intensity statin therapy, and guidelines recommend achieving at least a 50% reduction in LDL cholesterol from baseline or reaching specific LDL targets (typically <70-100 mg/dL depending on risk category) 1. A follow-up lipid panel should be ordered in 4-12 weeks after implementing these changes to assess response.
From the FDA Drug Label
As an adjunct to diet, alone or in combination with other low-density lipoprotein cholesterol (LDL-C)-lowering therapies, in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH), to reduce LDL-C The recommended dosage of REPATHA is either 140 mg every 2 weeks OR 420 mg once monthly administered subcutaneously
The patient is already on atorvastatin 40 mg and still has high cholesterol levels. Adding a new LDL-C lowering therapy such as evolocumab (REPATHA) may be considered to further reduce LDL-C levels. The recommended dosage of REPATHA is either 140 mg every 2 weeks or 420 mg once monthly administered subcutaneously 2.
- Key considerations:
- The patient's current LDL-C level is 143, which is still high despite being on atorvastatin 40 mg.
- The patient's HDL and triglyceride levels are 39 and 166, respectively.
- The patient's nHDL level is 176, which is also high.
- Next steps:
- Consider adding evolocumab (REPATHA) to the patient's current treatment regimen to further reduce LDL-C levels.
- Monitor the patient's LDL-C levels regularly to assess the effectiveness of the new treatment regimen.
- Also consider other options such as alirocumab (PRALUENT) as an adjunct to diet and other LDL-C lowering therapies in adults with primary hyperlipidemia, including HeFH, to reduce LDL-C 3.
From the Research
Patient's Current Condition
The patient is currently taking atorvastatin 40 mg and has the following lipid profile:
- Total cholesterol: 215
- HDL: 39
- Triglyceride: 166
- LDL: 143
- non-HDL: 176
Considerations for Next Steps
Given the patient's current lipid profile, the following considerations can be made:
- The patient's LDL level is still high, indicating that the current dose of atorvastatin may not be sufficient to achieve optimal lipid levels 4, 5, 6.
- Increasing the dose of atorvastatin to 80 mg may lead to further reductions in LDL levels, but may also increase the risk of myalgia 5, 6.
- Adding other lipid-lowering therapies, such as fenofibric acid or ezetimibe, to the patient's regimen may be considered to further improve lipid profiles 7, 8.
- The patient's triglyceride level is also elevated, which may require additional treatment considerations 7, 8.
Potential Next Steps
Based on the available evidence, potential next steps for the patient's treatment could include:
- Increasing the dose of atorvastatin to 80 mg to further reduce LDL levels 5, 6.
- Adding fenofibric acid or ezetimibe to the patient's regimen to improve lipid profiles, particularly for patients with mixed dyslipidemia 8.
- Considering alternative lipid-lowering therapies, such as niacin or anion exchange resins, to further improve lipid profiles 7.