From the Guidelines
For a 62-year-old patient with both elevated triglycerides (612 mg/dL) and cholesterol (226 mg/dL) who is already taking rosuvastatin 20 mg, adding fenofibrate (typically 145 mg daily) would be an appropriate additional medication. Fenofibrate specifically targets triglycerides while complementing the cholesterol-lowering effects of rosuvastatin. According to the guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease 1, if triglycerides are between 200-499 mg/dL, consideration should be given to adding a fibrate or niacin after LDL-lowering therapy. Although the patient's triglyceride level is above 500 mg/dL, the principle of adding a fibrate to target triglycerides remains relevant, as supported by the management of dyslipidemia in adults with diabetes guidelines 1, which suggest using fibric acid derivatives like fenofibrate for triglyceride lowering. Before starting fenofibrate, the patient should have liver function tests and creatinine levels checked, as these medications can affect both systems. Regular monitoring of lipid levels every 3-6 months is recommended to assess efficacy. The combination therapy works because statins like rosuvastatin primarily reduce LDL cholesterol through inhibiting HMG-CoA reductase, while fibrates activate peroxisome proliferator-activated receptors (PPARs), enhancing triglyceride clearance and reducing production. This dual approach addresses both lipid abnormalities more effectively than statin monotherapy alone. Key considerations include:
- Monitoring for potential side effects of fenofibrate, such as myositis, especially when combined with statins.
- Adjusting the dose of fenofibrate based on the patient's response and tolerance.
- Considering alternative treatments, such as omega-3 fatty acid supplements, if fenofibrate is not tolerated or effective.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Additional Medication Needed
The patient is already on rosuvastatin 20 mg, but still has elevated triglycerides (612 mg/dL) and cholesterol (226 mg/dL). To manage hypertriglyceridemia, the following options can be considered:
- Fibrates: can be used to reduce the risk of pancreatitis in patients with severely elevated triglyceride levels 2
- Omega-3 fatty acids: can be used to reduce triglyceride levels, with a dose of 4 g/d being effective in reducing triglycerides by ≥30% 3
- Icosapent (purified eicosapentaenoic acid): can be used to reduce cardiovascular mortality in patients with high triglyceride levels who are already on statin therapy 2
Considerations for Additional Medication
When choosing an additional medication, the following factors should be considered:
- The patient's 10-year risk of atherosclerotic cardiovascular disease: this can help determine the role of medications in managing hypertriglyceridemia 2
- The potential for drug interactions: combining rosuvastatin with other medications, such as fenofibrate or omega-3 fatty acids, may have effects on lipid profiles and other cardiovascular risk factors 4, 5
- The patient's individual response to treatment: monitoring lipid profiles and other cardiovascular risk factors can help determine the effectiveness of additional medication 4, 5
Potential Benefits and Risks of Additional Medication
The potential benefits of additional medication include:
- Reduced risk of pancreatitis: fibrates and omega-3 fatty acids can help reduce the risk of pancreatitis in patients with severely elevated triglyceride levels 2, 3
- Reduced cardiovascular risk: icosapent and omega-3 fatty acids can help reduce cardiovascular risk in patients with high triglyceride levels 2, 3 The potential risks of additional medication include:
- Increased risk of adverse effects: combining rosuvastatin with other medications may increase the risk of adverse effects, such as increased lipoprotein(a) levels 5