From the Guidelines
For a patient with a cholesterol level of 217 and triglyceride level of 272, a statin should be started as first-line therapy to reduce the risk of atherosclerotic cardiovascular disease (ASCVD) 1. The patient's age of 43 years and lipid profile suggest an increased risk of ASCVD, and according to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline, statin therapy is recommended for primary prevention in adults with LDL-C levels ≥ 70 mg/dL and a 10-year ASCVD risk ≥ 7.5% 1. Although the patient's 10-year ASCVD risk is not explicitly stated, the guideline suggests that a clinician-patient risk discussion should be held before starting statin therapy, considering factors such as cigarette smoking, elevated blood pressure, LDL-C, and calculated 10-year risk of ASCVD 1. Key points to consider in this patient's management include:
- Starting with a moderate-intensity statin and adjusting the dose or adding other therapies as needed to achieve target lipid levels 1
- Monitoring lipid levels regularly to assess response to therapy and adjust treatment accordingly
- Considering the addition of ezetimibe or other non-statin therapies if the patient's LDL-C level remains elevated despite statin therapy 1
- Emphasizing a heart-healthy lifestyle, including a healthy diet and regular physical activity, to reduce ASCVD risk 1.
From the FDA Drug Label
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 patient has hypercholesterolemia with a cholesterol level of 217 and hypertriglyceridemia with a triglyceride level of 272.
- Statin or Zetia (ezetimibe) can be considered as treatment options.
- According to the drug label, ezetimibe is indicated for use in combination with a statin to reduce elevated LDL-C in adults with primary hyperlipidemia.
- The decision to start a statin or Zetia (ezetimibe) should be based on the patient's individual needs and medical history, considering the potential benefits and risks of each treatment option 2, 2, 2.
- It is recommended to assess LDL-C levels when clinically appropriate, as early as 4 weeks after initiating ezetimibe tablets 2.
From the Research
Treatment Options for Hypercholesterolemia and Hypertriglyceridemia
The patient's cholesterol level of 217 and triglyceride level of 272 indicate hypercholesterolemia and hypertriglyceridemia. According to current guidelines, statins are recommended as first-line therapy for reducing low-density lipoprotein cholesterol (LDL-C) and preventing cardiovascular events 3. However, for patients who cannot tolerate statins, other LDL-C-lowering agents such as ezetimibe can be considered.
Ezetimibe as a Treatment Option
Ezetimibe is a highly-selective inhibitor of cholesterol absorption and can be used in combination with statins to produce more effective lipid lowering 4. The LDL-C-lowering efficacy of targeting both major sources of cholesterol with ezetimibe plus simvastatin was demonstrated in several multicentre, double-blind, placebo-controlled trials in patients with hypercholesterolaemia. For patients who do not reach their cholesterol goal with a statin, adding ezetimibe 10 mg significantly reduces LDL-C compared with statin monotherapy.
Combination Therapy with Statin and Ezetimibe
Combination therapy with a statin and ezetimibe can be an effective treatment option for patients with hypercholesterolemia and hypertriglyceridemia. Studies have shown that this combination provides greater LDL-C reduction and translates into a greater proportion of patients achieving lipid goals 5, 6. The atorvastatin-ezetimibe combination has also been shown to induce the regression of coronary atherosclerosis measured by intravascular ultrasound in a significantly greater proportion of patients than atorvastatin alone.
Key Points to Consider
- Statins are recommended as first-line therapy for reducing LDL-C and preventing cardiovascular events
- Ezetimibe can be used in combination with statins to produce more effective lipid lowering
- Combination therapy with a statin and ezetimibe can be an effective treatment option for patients with hypercholesterolemia and hypertriglyceridemia
- The choice of treatment should be based on the patient's individual needs and medical history, as well as the potential benefits and risks of each treatment option 7, 5
Potential Treatment Approach
Based on the patient's cholesterol and triglyceride levels, a potential treatment approach could be to start with a statin and then add ezetimibe if the patient's lipid goals are not achieved with statin monotherapy. However, the decision to start with a statin or ezetimibe, or to use combination therapy, should be made on a case-by-case basis, taking into account the patient's individual needs and medical history.