What is the management approach for a 72-year-old female with hypertriglyceridemia (elevated triglycerides), elevated Low-Density Lipoprotein (LDL) cholesterol, and hypercholesterolemia (elevated total cholesterol)?

From the Guidelines

This patient requires immediate initiation of lifestyle modifications and consideration of pharmacotherapy to manage her elevated triglycerides and LDL cholesterol, with a goal of reducing her LDL-C to less than 100 mg/dL and non-HDL-C to less than 130 mg/dL, as recommended by the AHA/ACC guidelines 1. The patient's lipid profile shows elevated triglycerides (302 mg/dL), borderline high total cholesterol (225 mg/dL), and slightly elevated LDL cholesterol (119 mg/dL).

Key Recommendations

• Start dietary therapy to reduce intake of saturated fats, trans-fatty acids, and cholesterol, and promote daily physical activity and weight management 1.
• Consider adding plant stanol/sterols (2 g/d) and viscous fiber (10 g/d) to further lower LDL-C, as well as encouraging increased consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g/d) for risk reduction 1.
• If triglycerides remain elevated after 3 months of lifestyle modifications, consider medication therapy with fenofibrate 145 mg daily or omega-3 fatty acids (icosapent ethyl 2 grams twice daily or omega-3 ethyl esters 2-4 grams daily) 1.
• For LDL management, a moderate-intensity statin like atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily may be appropriate based on her overall cardiovascular risk assessment 1. Some key points to consider in this patient's management include:
• Elevated triglycerides increase pancreatitis risk when >500 mg/dL and contribute to cardiovascular disease risk.
• The patient should have follow-up lipid testing in 3 months to assess response to interventions, and liver function tests should be monitored if statin therapy is initiated.
• The combination of high-dose statin plus fibrate can increase risk for severe myopathy, and statin doses should be kept relatively low with this combination 1.

From the FDA Drug Label

1. 1 Primary Hypercholesterolemia or Mixed Dyslipidemia Fenofibrate tablets are indicated as adjunctive therapy to diet to reduce elevated low-density lipoprotein cholesterol (LDL-C), total cholesterol (Total-C), Triglycerides and apolipoprotein B (Apo B), and to increase high-density lipoprotein cholesterol (HDL-C) in adult patients with primary hypercholesterolemia or mixed dyslipidemia. 2.2 Primary Hypercholesterolemia or Mixed Dyslipidemia The initial dose of fenofibrate tablet is 160 mg once daily. 2.5 Geriatric Patients Dose selection for the elderly should be made on the basis of renal function [see Use in Specific Populations (8. 5)].

The patient is a 72-year-old female with elevated triglycerides (302), LDL (119), and total cholesterol (225). Based on the drug label, fenofibrate is indicated for primary hypercholesterolemia or mixed dyslipidemia. The initial dose for this condition is 160 mg once daily. However, since the patient is elderly, the dose selection should be made on the basis of renal function 2.

• Key considerations:
  • Patient's renal function should be evaluated before initiating therapy.
  • Patient should be placed on an appropriate lipid-lowering diet before receiving fenofibrate tablets.
  • Lipid levels should be monitored periodically.
  • Dose adjustment may be necessary based on patient response and renal function.
• Recommended dose: The initial dose is 160 mg once daily, but this may need to be adjusted based on the patient's renal function 2.

From the Research

Patient's Lipid Profile

The patient has a triglyceride level of 302, LDL of 119, and total cholesterol of 225.

Treatment Options

• Statins are a class of lipid-lowering drugs that inhibit the de-novo synthesis of cholesterol, primarily lowering LDL cholesterol and, to a lesser extent, triglycerides 3.
• Fibrates are another class of lipid-lowering drugs that mainly lower triglycerides and also increase HDL cholesterol 3, 4.
• Combination therapy with statins and omega-3 fatty acids has been shown to be more effective in improving lipid profiles than statin monotherapy, except for LDL cholesterol 5.
• A fixed-dose combination of atorvastatin and fenofibrate has been found to achieve a greater percentage reduction in lipid profile than atorvastatin alone in patients with type 2 diabetes and dyslipidemia 6.

Lipid Goals Attainment

• A study found that only 13.2% of patients with a very high cardiovascular risk achieved the primary LDL-C goal during hospitalization, and 39% achieved it during follow-up 7.
• The study also found that patients with LDL-C < 55 mg% had a lower mortality rate at 12-month follow-up 7.

Medication Effects

• Atorvastatin has been shown to decrease all LDL subfractions, including small, dense LDL, and increase HDL cholesterol 4.
• Fenofibrate has been found to predominantly decrease triglyceride concentrations and induce a shift in LDL subtype distribution from small, dense LDL to intermediate-dense LDL 4.
• Omega-3 fatty acids have been found to have beneficial effects on lipid concentrations, but their potential to decrease vascular risk remains to be proven 3, 5.