What are the cholesterol management recommendations for a 29-year-old female with hyperlipidemia, elevated Lipoprotein(a) (Lp(a)), and a family history of myocardial infarction (MI), currently taking Crestor (rosuvastatin) and considering pregnancy?

From the Guidelines

For a 29-year-old female with hyperlipidemia, elevated Lp(a) in the upper 200s, family history of early MI, and planning pregnancy, I strongly recommend discontinuing Crestor (rosuvastatin) before conception as statins are contraindicated during pregnancy due to potential teratogenic effects, as suggested by the most recent guidelines 1. This recommendation is based on the latest evidence from the International Atherosclerosis Society guidance for implementing best practice in the care of familial hypercholesterolaemia, which advises that statins and other systemically absorbed cholesterol-lowering drugs should ideally be discontinued 3 months before planned conception and during pregnancy and lactation 1.

Key Considerations

• The patient's elevated Lp(a) and strong family history of early MI represent significant cardiovascular risk factors that warrant aggressive management outside of pregnancy, but during pregnancy and lactation, the focus shifts to non-pharmacological approaches to minimize fetal risk while maintaining maternal health.
• A heart-healthy Mediterranean-style diet rich in fruits, vegetables, whole grains, lean proteins, and omega-3 fatty acids should be adopted as a pregnancy-safe cholesterol management strategy.
• Regular moderate exercise (150 minutes weekly) should be maintained throughout pregnancy if medically cleared.
• Close monitoring of lipid levels before, during, and after pregnancy is essential to assess the need for adjustments in management.
• After delivery, if breastfeeding, continue non-pharmacological management until weaning, then discuss restarting statin therapy.

Preconception and Prenatal Care

• A preconception consultation with both a cardiologist and high-risk obstetrician would be beneficial to create a personalized management plan, considering the patient's specific risk factors and health status.
• The patient should be educated about the risks of pregnancy, the importance of contraception, and safer methods of contraception with minimal cardiovascular risk, as emphasized by recent guidelines 1.
• Family planning should be addressed early, involving LDL-cholesterol testing of the partner and counseling, especially in women with a significant family history of hypercholesterolaemia.

From the FDA Drug Label

8 USE IN SPECIFIC POPULATIONS 8. 1 Pregnancy Risk Summary Discontinue rosuvastatin when pregnancy is recognized. Alternatively, consider the ongoing therapeutic needs of the individual patient Rosuvastatin decreases synthesis of cholesterol and possibly other biologically active substances derived from cholesterol; therefore, rosuvastatin may cause fetal harm when administered to pregnant patients based on the mechanism of action

The patient should discontinue rosuvastatin when pregnancy is recognized, as it may cause fetal harm.

• The treatment of hyperlipidemia is not generally necessary during pregnancy.
• Atherosclerosis is a chronic process, and discontinuation of lipid-lowering drugs during pregnancy should have little impact on the outcome of long-term therapy of primary hyperlipidemia for most patients 2.
• It is recommended to consider the ongoing therapeutic needs of the individual patient 2.

From the Research

Recommendations for Cholesterol Management

Given the patient's history of hyperlipidemia, elevated Lp(a) levels, and family history of myocardial infarction, the following recommendations can be made:

• The patient is currently on crestor (rosuvastatin), which has been shown to be effective in improving lipid profiles and reducing LDL-C levels 3, 4.
• However, rosuvastatin may not be effective in reducing Lp(a) levels, and in some cases, may even increase Lp(a) levels 5.
• Considering the patient's elevated Lp(a) levels, alternative treatment options may be necessary to reduce Lp(a) levels and manage ASCVD risk.
• The use of ezetimibe in combination with rosuvastatin may be considered, as it has been shown to be safe and effective in reducing LDL-C levels and improving lipid profiles 6.
• It is essential to monitor the patient's lipid profiles and Lp(a) levels regularly to assess the effectiveness of the treatment and make any necessary adjustments.

Considerations for Pregnancy

• When considering pregnancy, it is crucial to weigh the benefits and risks of continuing or modifying the patient's current treatment regimen.
• Statins, including rosuvastatin, are generally contraindicated during pregnancy due to the potential risk of fetal harm.
• Alternative treatment options, such as lifestyle modifications and dietary changes, may be recommended to manage the patient's lipid profiles and reduce ASCVD risk during pregnancy.
• Close monitoring of the patient's lipid profiles and Lp(a) levels is necessary to ensure that any changes to the treatment regimen do not increase the risk of ASCVD or other complications 7, 3.