What is the treatment for mixed hyperlipidemia?

From the Guidelines

Mixed hyperlipidemia treatment should prioritize statin therapy as the first-line medication, with lifestyle modifications including dietary changes and regular exercise, to reduce the risk of cardiovascular disease and improve quality of life. The treatment approach should be individualized based on cardiovascular risk, with regular monitoring of lipid levels. According to the most recent and highest quality study 1, statins are the drugs of choice for lowering LDL cholesterol, and lifestyle intervention, including medical nutrition therapy, increased physical activity, weight loss, and smoking cessation, may allow some patients to reach lipid goals.

Key lifestyle modifications include:

• Reduced saturated fat, trans fat, and cholesterol intake
• Increased fiber consumption
• Regular exercise (at least 150 minutes of moderate activity weekly)
• Weight management
• Smoking cessation
• Limiting alcohol consumption

For medications, the following options can be considered:

• Statins, such as atorvastatin (10-80 mg daily) or rosuvastatin (5-40 mg daily), as first-line therapy
• Adding fenofibrate (48-145 mg daily) or omega-3 fatty acids (2-4 g daily) if triglycerides remain elevated despite statin therapy
• Ezetimibe (10 mg daily) can be added to statin therapy for patients with very high LDL levels
• PCSK9 inhibitors like evolocumab or alirocumab may be considered for those with familial hypercholesterolemia or statin intolerance, as suggested by 1.

It is essential to note that the decision to start pharmacological therapy should be based on the clinician's judgment, considering the patient's individual cardiovascular risk and lipid levels. Regular monitoring of lipid levels every 3-6 months initially, then annually once stable, is crucial to adjust the treatment plan as needed. By prioritizing statin therapy and lifestyle modifications, patients with mixed hyperlipidemia can reduce their risk of cardiovascular disease and improve their overall quality of life, as supported by the study 1.

From the FDA Drug Label

Combination with Fenofibrate In a multicenter, double-blind, placebo-controlled, clinical trial in patients with mixed hyperlipidemia, 625 patients (age range 20 to 76 years, 44% female; 79% White, 1% Black or African American, 20% other races; and 11% identified as Hispanic or Latino ethnicity) were treated for up to 12 weeks and 576 for up to an additional 48 weeks Patients were randomized to receive placebo, ezetimibe tablet alone, 160 mg fenofibrate alone, or ezetimibe tablet and 160 mg fenofibrate in the 12-week trial. After completing the 12-week trial, eligible patients were assigned to ezetimibe tablet coadministered with fenofibrate or fenofibrate monotherapy for an additional 48 weeks Ezetimibe Tablet coadministered with fenofibrate significantly lowered total-C, LDL-C, Apo B, and non-HDL-C compared to fenofibrate administered alone (see Table 12)

TABLE 12: Response to Ezetimibe Tablet and Fenofibrate Initiated Concurrently in Patients with Mixed Hyperlipidemia (Mean % Change from Untreated Baseline* at 12 weeks) Treatment (Daily Dose) N Total-C LDL-C Apo B Non-HDL-C Placebo 63 0 0 -1 0 Ezetimibe Tablet 185 -12 -13 -11 -15 Fenofibrate 160 mg 188 -11 -6 -15 -16 Ezetimibe Tablet + Fenofibrate 160 mg 183 -22 -20 -26 -30

The treatment for mixed hyperlipidemia is ezetimibe tablet coadministered with fenofibrate, which significantly lowers total-C, LDL-C, Apo B, and non-HDL-C compared to fenofibrate administered alone 2.

• Key benefits of this treatment include:
  • Significant reduction in LDL-C and non-HDL-C
  • Improvement in lipid profile
• Recommended dosage: Ezetimibe tablet and 160 mg fenofibrate.

From the Research

Treatment Options for Mixed Hyperlipidemia

The treatment for mixed hyperlipidemia involves a combination of lifestyle modifications and pharmacological interventions. Some of the key treatment options include:

• Combination therapy with fenofibrate and other drugs such as bile acid sequestrants, ezetimibe, niacin, n-3 fatty acids, plant sterols, orlistat, rimonabant, metformin, and glitazones 3
• Rosuvastatin alone or in combination with fenofibrate or omega-3 fatty acids to reduce lipoprotein(a) levels 4
• Combination of statin and fibrate therapy to achieve better overall lipid control 5
• Use of fibric acid derivatives, hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, and nicotinic acid as monotherapy or in combination to manage combined hyperlipidemia 6

Pharmacological Interventions

Pharmacological interventions play a crucial role in the management of mixed hyperlipidemia. Some of the key pharmacological interventions include:

• Fenofibrate: a fibric acid derivative that has greater effects on triglycerides and can be used in combination with other drugs 3, 5
• Rosuvastatin: a statin that can be used alone or in combination with fenofibrate or omega-3 fatty acids to reduce lipoprotein(a) levels 4
• HMG-CoA reductase inhibitors: can be used to reduce LDL-C levels and have effects on other cardiovascular risk factors 6
• Nicotinic acid: can be used to manage combined hyperlipidemia and has effects on HDL-C and triglyceride levels 6

Lifestyle Modifications

Lifestyle modifications also play a crucial role in the management of mixed hyperlipidemia. Some of the key lifestyle modifications include:

• Dietary changes: modification of the typical American diet to reduce cholesterol, fat, and sodium intake 7
• Exercise: regular physical activity to reduce plasma lipids and coronary risk 7
• Smoking cessation: quitting cigarette smoking to reduce coronary risk 7
• Medication adherence: adhering to prescribed medication regimens to reduce plasma lipids and coronary risk 7