What guidance should be given to a 37-year-old male with elevated Very Low-Density Lipoprotein (VLDL) cholesterol, high Low-Density Lipoprotein (LDL) cholesterol, low High-Density Lipoprotein (HDL) cholesterol, and hypertriglyceridemia?

From the Guidelines

This patient requires immediate lifestyle modifications and potentially medication therapy to address elevated triglycerides and low HDL, targeting a reduction in cardiovascular risk and improvement in lipid profiles. The patient's lipid profile shows elevated triglycerides (343 mg/dL) and low HDL (31 mg/dL), indicating dyslipidemia that necessitates intervention 1. Given the patient's lipid profile, the primary goal is to reduce triglycerides and increase HDL through lifestyle modifications, including:

• A Mediterranean-style diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats like olive oil and nuts
• Reduction of refined carbohydrates, sugary beverages, and alcohol
• Regular exercise of at least 150 minutes per week of moderate-intensity activity
• Weight loss of 5-10% of body weight, if overweight If after 3 months of lifestyle changes, triglycerides remain elevated or cardiovascular risk is high, medication therapy with fibrates (such as fenofibrate 145 mg daily) or prescription omega-3 fatty acids (4 g daily) may be indicated 1. A statin may also be considered to address overall cardiovascular risk, aiming for an LDL-C goal of <100 mg/dL, with a potential option for further reduction to <70 mg/dL in high-risk patients 1. These recommendations prioritize the reduction of cardiovascular risk and improvement in lipid profiles, aligning with the most recent guidelines for lipid management and cardiovascular risk reduction 1.

From the FDA Drug Label

The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality. Excess body weight and excess alcoholic intake may be important factors in hypertriglyceridemia and should be addressed prior to any drug therapy. Physical exercise can be an important ancillary measure Diseases contributory to hyperlipidemia, such as hypothyroidism or diabetes mellitus should be looked for and adequately treated.

The patient has elevated triglycerides (343 mg/dL), low HDL (31 mg/dL), and elevated LDL (125 mg/dL).

• The patient should be advised to start with dietary therapy and lifestyle modifications such as:
  • Reducing excess body weight
  • Decreasing alcoholic intake
  • Increasing physical exercise
• The patient should also be evaluated for any underlying diseases that may be contributing to the hyperlipidemia, such as hypothyroidism or diabetes mellitus, and these conditions should be adequately treated.
• Consideration should be given to starting the patient on fenofibrate therapy, with an initial dose of 54-160 mg per day, depending on the severity of the hypertriglyceridemia and the patient's response to treatment 2.

From the Research

Patient Guidance

The patient's lipid profile shows elevated triglycerides (343 mg/dL) and LDL (125 mg/dL) levels, with low HDL (31 mg/dL) levels. Based on the studies, the following guidance can be provided:

• The patient's triglyceride level is elevated, which is a risk factor for cardiovascular disease (CVD) and acute pancreatitis 3.
• Statins are the first line of therapy for managing mild to moderate hypertriglyceridemia, and they can reduce mean triglyceride levels by up to 18% 3.
• However, the patient may need additional reduction in triglyceride-rich lipoproteins and remnant particles to further reduce residual CVD risk 3.
• Combination treatment with atorvastatin plus niacin may provide more complete normalization of the lipid profile and increased cardiovascular benefits 4.
• Lifestyle modifications, including physical activity and a moderately reduced-calorie diet, are first-line therapy for patients with elevated blood pressure and cholesterol 5, 6.
• Increasing physical activity has extensive benefits, including improving both blood pressure and blood cholesterol, and is an excellent lifestyle behavior treatment option for all patients 5.

Treatment Options

The following treatment options can be considered:

• Statin therapy to lower LDL cholesterol and triglyceride levels 3, 7.
• Addition of fibrates, niacin, or long-chain omega-3 fatty acids if elevated triglyceride or non-high-density lipoprotein cholesterol levels persist despite statin therapy 3, 4, 7.
• Lifestyle modifications, including physical activity and a healthy diet, to improve lipid profiles and reduce cardiovascular risk 5, 6.

Lifestyle Modifications

The patient can be advised to:

• Engage in at least 150 to 300 min/week of moderate-intensity or 75 to 150 min/week of vigorous-intensity aerobic physical activity 5, 6.
• Follow a moderately reduced-calorie diet to achieve a modest weight loss of 5% to 10% 6.
• Use behavior strategies, such as motivational interviewing and cognitive behavior therapy, to facilitate adherence to lifestyle modifications 6.