What are alternative treatments to statins (HMG-CoA reductase inhibitors) for managing hypercholesterolemia and hypertriglyceridemia in a patient with tendinitis?

From the Guidelines

For patients with high cholesterol and triglycerides who cannot take statins due to tendinitis, PCSK9 inhibitors like evolocumab (Repatha) or alirocumab (Praluent) are excellent alternatives, as they can lower LDL cholesterol by 50-70% and have been shown to reduce cardiovascular risk 1. These medications are administered as subcutaneous injections every 2-4 weeks.

• Ezetimibe (Zetia), taken as a 10mg daily oral tablet, is another option that reduces cholesterol absorption in the intestine and can lower LDL by 15-20% 1.
• For triglyceride management specifically, prescription-strength omega-3 fatty acids like icosapent ethyl (Vascepa, 2g twice daily) or omega-3 acid ethyl esters (Lovaza, 4g daily) are effective 1.
• Fibrates such as fenofibrate (145mg daily) can also reduce triglycerides by 30-50% 1. Non-pharmacological approaches are equally important:
• adopting a Mediterranean diet rich in olive oil, nuts, and fatty fish
• regular exercise (150 minutes weekly of moderate activity)
• weight management
• limiting alcohol
• and increasing soluble fiber intake (10-25g daily) These alternatives work through different mechanisms than statins, avoiding the muscle and tendon effects while still providing cardiovascular protection. It is worth noting that the most recent guidelines from the American College of Cardiology recommend the use of non-statin therapies, such as PCSK9 inhibitors and ezetimibe, for patients who cannot tolerate statins or require additional LDL-lowering therapy 1.

From the FDA Drug Label

Fenofibrate tablets are indicated as adjunctive therapy to diet to reduce elevated low-density lipoprotein cholesterol (LDL-C), total cholesterol (Total-C), Triglycerides and apolipoprotein B (Apo B), and to increase high-density lipoprotein cholesterol (HDL-C) in adult patients with primary hypercholesterolemia or mixed dyslipidemia. Fenofibrate tablets are also indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia.

Alternative to statins: Fenofibrate may be considered as an alternative to statins for controlling high cholesterol and high triglycerides, especially in patients with severe hypertriglyceridemia.

• Key benefits: Fenofibrate can help reduce LDL-C, Total-C, Triglycerides, and Apo B, while increasing HDL-C.
• Important considerations: Patients should be placed on an appropriate lipid-lowering diet before receiving fenofibrate and should continue this diet during treatment.
• Dosage: The initial dose of fenofibrate is 160 mg once daily for primary hypercholesterolemia or mixed dyslipidemia, and 54-160 mg per day for severe hypertriglyceridemia. 2

From the Research

Alternatives to Statins for Controlling High Cholesterol and Triglycerides

• For patients with high triglyceride levels, alternatives to statins can be considered, especially if they have tendinitis or other conditions that may be exacerbated by statin use 3, 4.
• Dietary changes and physical activity can help lower triglyceride levels, and may be sufficient for patients with mild to moderate hypertriglyceridemia 3.
• For patients with severely elevated triglyceride levels, fibrates, omega-3 fatty acids, or niacin may be considered to reduce the risk of pancreatitis 3.
• Ezetimibe, bile acid sequestrants, and combinations of these medications with statins or other agents may also be effective for lowering LDL cholesterol and triglyceride levels 5, 6.
• It is worth noting that while statins have been associated with an increased risk of tendinitis in some cases, the evidence for this relationship is not strong, and simvastatin may actually reduce the risk of tendinopathy 7.

Considerations for Patients with Tendinitis

• Patients with tendinitis who are concerned about the potential risks of statin use may want to discuss alternative treatment options with their healthcare provider 7.
• A thorough evaluation of the patient's individual risk factors and medical history can help determine the best course of treatment for managing high cholesterol and triglyceride levels while minimizing the risk of exacerbating tendinitis 3, 4.
• Regular monitoring of lipid levels and other cardiovascular risk factors can help healthcare providers adjust treatment plans as needed to ensure optimal management of high cholesterol and triglycerides 5, 6.