What is the management approach for a 69-year-old female with hypertriglyceridemia on atorvastatin (atorvastatin) 80 mg daily?

From the Guidelines

For a 69-year-old female with triglycerides of 225 mg/dL who is already on atorvastatin 80 mg daily, I recommend adding omega-3 fatty acid supplements (2-4 grams daily) and implementing lifestyle modifications including a Mediterranean diet, limiting alcohol and simple carbohydrates, increasing physical activity, and weight loss if needed. While the patient's triglyceride level is only moderately elevated (borderline high range: 150-499 mg/dL), addressing it is important since elevated triglycerides increase cardiovascular risk, especially in older adults 1. Atorvastatin primarily targets LDL cholesterol and has modest effects on triglycerides, which explains why her triglycerides remain elevated despite high-dose statin therapy. Some key points to consider in the management of this patient include:

• The importance of assessing and managing other cardiovascular risk factors, such as central obesity, hypertension, abnormal glucose metabolism, and liver dysfunction 1.
• The role of dietary counseling and weight loss in patients who are overweight or obese, as well as reduced intake of dietary fat and simple carbohydrates in patients with severe to very severe hypertriglyceridemia 1.
• The use of fibrates, niacin, and n-3 fatty acids, alone or in combination, in patients with moderate to severe hypertriglyceridemia 1. If these interventions don't reduce triglycerides below 150 mg/dL after 3 months, consider adding fenofibrate, though monitor for potential statin-fibrate interaction effects including muscle symptoms and liver function changes 1. Also ensure diabetes is ruled out or well-controlled, as uncontrolled diabetes can significantly elevate triglycerides. Regular monitoring of her lipid panel every 3-6 months is recommended to assess treatment efficacy.

From the FDA Drug Label

Atorvastatin calcium reduces total-C, LDL-C, apo B, and TG, and increases HDL-C in patients with hyperlipidemia (heterozygous familial and nonfamilial) and mixed dyslipidemia

The patient is already on atorvastatin 80 mg daily, which is the highest dose, and still has elevated triglycerides of 225.

• Triglyceride reduction: The label states that atorvastatin reduces TG, but it does not provide specific information on the degree of reduction that can be expected in a patient with a baseline TG level of 225.
• Dose: The patient is already on the maximum recommended dose of atorvastatin (80 mg daily) 2. It is unclear if adding another medication or changing the current treatment regimen would be beneficial for this patient.

From the Research

Patient Profile

• 69-year-old female
• Triglycerides: 225 mg/dL
• Currently taking atorvastatin 80 mg daily

Management of Hypertriglyceridemia

• According to 3, hypertriglyceridemia is associated with increased risk of cardiovascular disease and pancreatitis
• Management of high triglyceride levels starts with dietary changes and physical activity to lower cardiovascular risk
• Statins, such as atorvastatin, can be considered for patients with high triglyceride levels who have borderline or intermediate risk of atherosclerotic cardiovascular disease

Treatment Options

• 4 suggests that fibrates, niacin, or long-chain omega-3 fatty acids can be added to statin therapy if elevated triglyceride or non-high-density lipoprotein cholesterol levels persist
• 5 found that the addition of omega-3 fatty acids to atorvastatin improved triglyceride and non-high-density lipoprotein cholesterol levels in patients with residual hypertriglyceridemia
• 6 notes that niacin is the most potent HDL-increasing drug currently available and also lowers triglycerides and LDL cholesterol

Considerations for This Patient

• Given the patient's triglyceride level of 225 mg/dL, additional treatment options such as omega-3 fatty acids or fibrates could be considered to further reduce triglyceride levels
• However, as noted in 7, rosuvastatin and/or fenofibrate treatment may increase lipoprotein(a) levels, which is a strong pathogenetic factor of atherosclerotic cardiovascular disease
• The patient's current atorvastatin dose of 80 mg daily is already high, so adding another medication may be a better option than increasing the atorvastatin dose further