What is the best approach to managing atherosclerosis of the aorta with statin therapy in a patient with elevated LDL cholesterol and acute gastritis?

From the Guidelines

For a patient with atherosclerosis of the aorta, elevated LDL cholesterol, and acute gastritis, the best approach is to initiate moderate-intensity statin therapy with careful consideration of the gastritis, aiming for an LDL-C goal of <1.4 mmol/L (<55 mg/dL) and a >50% reduction in LDL-C vs. baseline, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.

Key Considerations

• Start with rosuvastatin 10 mg or atorvastatin 20 mg daily, taken with food to minimize gastrointestinal irritation, as these statins have a lower risk of gastrointestinal side effects.
• Simultaneously, treat the acute gastritis with a proton pump inhibitor such as omeprazole 20 mg once daily for 2-4 weeks, along with dietary modifications including avoiding spicy foods, alcohol, and NSAIDs, as recommended by the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1.
• Once the gastritis resolves, the statin dose can be titrated upward if needed to achieve the desired LDL reduction, with regular monitoring of liver function tests and lipid panels.

Rationale

• The 2024 ESC guidelines for the management of peripheral arterial and aortic diseases recommend lipid-lowering therapy in patients with atherosclerotic PAAD, with an ultimate LDL-C goal of <1.4 mmol/L (55 mg/dL) and a >50% reduction in LDL-C vs. baseline 1.
• Statins are recommended as the first-line treatment for lipid-lowering therapy in patients with atherosclerotic PAAD, with the option to add ezetimibe or a PCSK9 inhibitor if the target LDL-C level is not achieved on maximally tolerated statins.
• The use of proton pump inhibitors is recommended in patients receiving aspirin monotherapy, DAPT, DAT, TAT, or OAC monotherapy who are at high risk of gastrointestinal bleeding, as recommended by the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1.

From the FDA Drug Label

EZETIMIBE tablets, for oral use INDICATIONS AND USAGE EZETIMIBE Tablets is indicated (1): • In combination with a statin, or alone when additional low density lipoprotein cholesterol (LDL-C) lowering therapy is not possible, as an adjunct to diet to reduce elevated LDL-C in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH)

The best approach to managing atherosclerosis of the aorta with statin therapy in a patient with elevated LDL cholesterol and acute gastritis is to use ezetimibe in combination with a statin as an adjunct to diet to reduce elevated LDL-C. However, the presence of acute gastritis may require careful consideration of the potential risks and benefits of statin therapy.

• Monitor liver enzyme testing as clinically indicated and consider withdrawal of ezetimibe if increases in ALT or AST ≥3 X ULN persist 2.
• Skeletal muscle effects (e.g., myopathy and rhabdomyolysis) may occur, and if myopathy is suspected, discontinue ezetimibe and other concomitant medications, as appropriate 2.

From the Research

Managing Atherosclerosis of the Aorta with Statin Therapy

• The patient has atherosclerosis of the aorta with elevated LDL cholesterol (130 mg/dL) and acute gastritis, and will start statin therapy 3, 4.
• Statin therapy is a common treatment for atherosclerosis, as it helps to reduce plasma cholesterol levels by inhibiting the synthesis of cholesterol in the liver 3.
• The goal of statin therapy is to reduce the level of low-density lipoprotein cholesterol (LDL-C) in the blood, which is a major risk factor for atherosclerotic cardiovascular disease (ASCVD) 4.

Considerations for Patients with Acute Gastritis

• Acute gastritis is an inflammation of the stomach lining, and it is not directly related to atherosclerosis or statin therapy 5.
• However, patients with acute gastritis may need to be monitored closely while taking statins, as some statins may increase the risk of gastrointestinal side effects 6.
• The presence of acute gastritis does not necessarily affect the decision to start statin therapy, but it may require closer monitoring and adjustment of the treatment plan as needed 7.

Treatment Options for Atherosclerosis

• Statin-ezetimibe combination treatment is a common approach for managing elevated LDL-C levels, and it may be considered for patients with atherosclerosis of the aorta 5.
• Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors may also be used to lower LDL-C levels in patients who do not respond to statin therapy alone 3, 5.
• The choice of treatment will depend on the individual patient's needs and medical history, and it is important to carefully weigh the benefits and risks of each treatment option 4, 7.