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 while on Crestor, I recommend discontinuing Crestor before conception, as statins like Crestor (rosuvastatin) are contraindicated during pregnancy due to potential teratogenic effects and should be stopped at least 1-3 months before attempting conception 1.

Key Considerations

• The patient's elevated Lp(a) and strong family history of early MI represent significant cardiovascular risk factors that warrant close monitoring and aggressive management outside of pregnancy 1.
• During pregnancy, focus on lifestyle modifications including a heart-healthy diet low in saturated fats, regular moderate exercise, and weight management 1.
• After delivery, if breastfeeding, statins remain contraindicated, but once breastfeeding is complete, Crestor can be resumed, typically at the previous effective dose 1.

Management Approach

• Pre-pregnancy counselling should be offered to all women before starting a statin, ezetimibe, PCSK9 inhibitor or other lipid-modifying therapies, and this advice should be reinforced as clinically indicated 1.
• Assessment of ASCVD using imaging should be offered to women with high-risk HeFH before a planned pregnancy 1.
• Bile acid sequestrants should be considered to treat hypercholesterolaemia, ideally 3 months before a planned pregnancy, as well as during pregnancy and lactation 1.

Cardiovascular Risk Assessment

• The patient's cardiovascular risk should be carefully assessed and managed throughout the pregnancy period, considering the temporary discontinuation of lipid-lowering therapy 1.
• Consultation with both a cardiologist and maternal-fetal medicine specialist is recommended for personalized care during pregnancy planning 1.

From the FDA Drug Label

Available data from case series and prospective and retrospective observational cohort studies over decades of use with statins in pregnant women have not identified a drug-associated risk of major congenital malformations Published data from prospective and retrospective observational cohort studies with rosuvastatin use in pregnant women are insufficient to determine if there is a drug-associated risk of miscarriage The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U. S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively

The patient is currently on rosuvastatin (Crestor) and considering pregnancy.

• The FDA drug label does not provide sufficient information to determine the risk of miscarriage associated with rosuvastatin use in pregnant women.
• However, available data from case series and observational cohort studies over decades of use with statins in pregnant women have not identified a drug-associated risk of major congenital malformations.
• Given the patient's history of hyperlipidemia and elevated LPa, as well as her family history of MI, it is essential to weigh the benefits and risks of continuing statin therapy during pregnancy.
• Considering the lack of sufficient data on rosuvastatin use in pregnant women, a conservative clinical decision would be to stop statin therapy during pregnancy, unless the benefits of continuing therapy outweigh the potential risks 2.

From the Research

Cholesterol Management Recommendations

The patient is a 29-year-old female with a history of hyperlipidemia and elevated LP(a) levels, currently on Crestor (rosuvastatin) and considering pregnancy. Based on the provided studies, the following recommendations can be made:

• The patient is already on rosuvastatin, which has been shown to be effective in improving lipid profiles and reducing LDL-C levels 3, 4, 5.
• However, studies have also shown that statin therapy, including rosuvastatin, can increase LP(a) levels 6, 7.
• The patient's elevated LP(a) levels and family history of myocardial infarction (MI) at a young age (43) suggest a high risk of cardiovascular disease.
• Considering the patient's plans for pregnancy, it is essential to weigh the benefits and risks of continuing statin therapy during pregnancy. However, there is no direct evidence provided in the studies to support a specific recommendation for cholesterol management during pregnancy.

Lipoprotein(a) Management

• Elevated LP(a) levels are a strong, genetically determined risk factor for atherosclerotic cardiovascular disease (ASCVD) 6.
• The studies suggest that statin therapy, including rosuvastatin, can increase LP(a) levels, which may offset some of the benefits of LDL-C reduction 6, 7.
• Novel therapies targeting LP(a) level reduction may be necessary to decrease residual ASCVD risk in patients with mixed hyperlipidemia 6.

Treatment Considerations

• Rosuvastatin has been shown to be well-tolerated and effective in improving lipid profiles, but its effect on LP(a) levels should be considered 3, 4, 5.
• The patient's treatment plan should be individualized, taking into account her high risk of cardiovascular disease, elevated LP(a) levels, and plans for pregnancy.
• Regular monitoring of lipid profiles, including LP(a) levels, and cardiovascular risk factors is essential to adjust the treatment plan as needed.