What is the best management option for a patient with Chronic Kidney Disease (CKD) stage 3a, currently on 40 mg of pravastatin, with a lipid profile showing hypercholesterolemia, hypertriglyceridemia, low High-Density Lipoprotein (HDL) cholesterol, and elevated Low-Density Lipoprotein (LDL) cholesterol?

From the Guidelines

The best option for this patient is to increase the pravastatin dose to 80 mg daily or switch to a more potent statin such as atorvastatin 20-40 mg or rosuvastatin 10-20 mg, as the current LDL level of 92 mg/dL is above the recommended target of <70 mg/dL for patients with chronic kidney disease, according to the most recent guideline 1. The patient's lipid panel results show a cholesterol level of 158 mg/dL, triglycerides of 147 mg/dL, HDL of 37 mg/dL, and LDL of 92 mg/dL, indicating that the current statin therapy is not sufficient to achieve the desired LDL level.

• The current pravastatin dose of 40 mg has provided some lipid-lowering effect, but intensifying statin therapy would likely provide additional cardiovascular benefit, as stated in the 2025 guideline 1.
• When making this change, it's essential to monitor liver function tests and creatine kinase, particularly in the setting of CKD.
• Rosuvastatin would require dose adjustment for CKD 3a (maximum 10 mg daily), as noted in the study 1.
• Lifestyle modifications should also be emphasized, including a heart-healthy diet, regular physical activity, smoking cessation if applicable, and weight management, to complement statin therapy and help improve the overall lipid profile, particularly the triglyceride and HDL levels.
• The use of non-statin agents such as ezetimibe or PCSK9 inhibitors may be considered if the patient is unable to achieve adequate LDL-C reduction with statin therapy alone, as discussed in the 2022 study 1.

From the FDA Drug Label

Median (25th, 75th percentile) percent changes from baseline after 6 months of pravastatin treatment in Total-C, LDL-C, TG, and HDL-C were -20.3 (-26.9, -11. 7), -27.7 (-36.0, -16.9), -9.1 (-27.6,12.5), and 6.7 (-2.1,15.6), respectively. The risk reduction due to treatment with pravastatin on CHD mortality was consistent regardless of age Pravastatin significantly reduced the risk for total mortality (by reducing CHD death) and CHD events (CHD mortality or nonfatal MI)

The patient's current Lipid panel results are:

• Cholesterol: 158 mg/dL
• Triglycerides: 147 mg/dL
• HDL: 37 mg/dL
• LDL: 92 mg/dL Given the patient is already on 40 mg of pravastatin and has CKD 3a, the current treatment appears to be effective in managing their lipid profile, with an LDL level of 92 mg/dL. No changes to the current treatment regimen are recommended based on the provided information 2.

From the Research

Patient's Current Status

• The patient is currently taking 40 mg of pravastatin and has chronic kidney disease (CKD) stage 3a.
• The patient's lipid panel results are: Cholesterol 158, triglycerides 147, HDL 37, and LDL 92.

Treatment Options

• According to the study 3, high-intensity statins are recommended for patients with atherosclerotic cardiovascular disease (ASCVD) or high-risk patients without clinical ASCVD.
• However, the patient's current statin dose is moderate-intensity, and switching to a high-intensity statin may not be necessary given their CKD status.
• The study 4 suggests that a therapeutic conversion program, which involves switching statin therapy under the guidance of a clinical pharmacist, can be effective in achieving patient-specific goals for low-density lipoprotein cholesterol (LDL).
• Another option is to add a non-statin drug, such as ezetimibe, to the patient's current statin regimen, as suggested by the study 3.
• The study 5 discusses the use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors as an adjunct to statin therapy in very high-risk patients, but this may not be necessary for the current patient.

Considerations for CKD Patients

• The study 6 notes that statins can increase the risk of renal dysfunction, which is a concern for patients with CKD.
• However, the study 7 suggests that alternate-day dosing of statins, such as pravastatin, may be as efficacious as daily dosing in terms of LDL reduction, which could be a consideration for patients with CKD.

Potential Next Steps

• Consult with a clinical pharmacist to discuss the patient's current statin regimen and potential options for optimizing their lipid profile.
• Consider adding a non-statin drug, such as ezetimibe, to the patient's current statin regimen to further reduce LDL levels.
• Monitor the patient's kidney function and adjust their statin regimen as needed to minimize the risk of renal dysfunction.