From the Guidelines
I strongly recommend increasing the atorvastatin dose to 40-80 mg daily and adding fenofibrate 145 mg daily to address the severely elevated triglycerides and LDL levels in this patient. The current atorvastatin dose appears insufficient as evidenced by the LDL of 143 mg/dL (target typically <100 mg/dL) and triglycerides of 404 mg/dL (normal <150 mg/dL) 1. According to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline, the presence of elevated triglycerides (>175 mg/dL) and LDL-C (160-189 mg/dL) are considered risk-enhancing factors for atherosclerotic cardiovascular disease (ASCVD) 1.
The patient's A1c of 5.6% is borderline prediabetic, suggesting insulin resistance may be contributing to the dyslipidemia 1. Triglycerides this high (>400 mg/dL) increase pancreatitis risk and require aggressive management. Lifestyle modifications are also crucial, including reducing simple carbohydrate and alcohol intake, increasing physical activity, and considering omega-3 fatty acid supplements (2-4 grams daily) 1. The combination therapy works by different mechanisms - atorvastatin primarily reduces LDL by inhibiting cholesterol synthesis, while fenofibrate specifically targets triglyceride metabolism through PPAR-alpha activation.
Key considerations in managing this patient's dyslipidemia include:
- Monitoring liver enzymes and muscle symptoms with this combination therapy
- Rechecking lipids in 6-8 weeks to assess response
- Optimizing glycemic control to beneficially modify plasma lipid levels, particularly in patients with very high triglycerides and poor glycemic control 1
- Applying a Mediterranean diet or Dietary Approaches to Stop Hypertension (DASH) dietary pattern to improve the lipid profile and reduce the risk of developing ASCVD 1.
From the Research
Patient's Lipid Profile
- The patient is a male taking atorvastatin with an A1c of 5.6, triglycerides of 404, and LDL of 143.
- According to 2, elevated triglyceride levels are independently associated with cardiovascular disease (CVD) risk, and severe hypertriglyceridemia is a risk factor for acute pancreatitis.
- The patient's triglyceride level is 404, which is considered high and may require additional treatment to reduce the risk of CVD.
Effectiveness of Atorvastatin
- Atorvastatin is a synthetic hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor that reduces levels of total cholesterol, low-density lipoprotein (LDL)-cholesterol, triglyceride, and very low-density lipoprotein (VLDL)-cholesterol, and increases high-density lipoprotein (HDL)-cholesterol 3.
- Studies have shown that atorvastatin decreases blood total cholesterol and LDL-cholesterol in a linear dose-related manner over the commonly prescribed dose range 4, 5.
- The patient is already taking atorvastatin, but the dosage is not specified. According to 4, the dose-related effects of atorvastatin on blood lipids are linear over the commonly prescribed dose range of 10 to 80 mg/day.
Additional Treatment Options
- The addition of omega-3 fatty acids to atorvastatin may further improve the risk profile for CHD in patients with combined hyperlipemia by reducing postprandial hyperlipemia and redistributing LDL subfractions 6.
- Fibrates, niacin, or long-chain omega-3 fatty acids may be considered as additional treatment options if elevated triglyceride or non-high-density lipoprotein cholesterol levels persist despite the use of high-intensity statin therapy 2.