What can be added to atorvastatin (HMG-CoA reductase inhibitor) for managing hypertriglyceridemia?

Management Options for High Triglycerides When on Atorvastatin

For patients with high triglycerides who are already on atorvastatin, adding a fibrate (specifically fenofibrate) is the most appropriate next step for triglyceride reduction while minimizing risk of adverse effects.

Initial Assessment and Optimization

Before adding another medication:

• Ensure optimal glycemic control (if diabetic)
• Verify patient is following dietary recommendations:
  • Reduced saturated fat intake
  • Limited alcohol consumption
  • Weight loss if overweight/obese
  • Increased physical activity
  • Reduced simple carbohydrate intake

Treatment Algorithm Based on Triglyceride Levels

For Triglycerides 175-499 mg/dL:

1. First option: Add icosapent ethyl (4g/day)

   • Most recent evidence shows cardiovascular risk reduction 1
   • Demonstrated 25% relative risk reduction in cardiovascular events
   • Specifically beneficial for patients with controlled LDL but elevated triglycerides
   • Minimal drug interactions with statins

2. Second option: Add fenofibrate

   • Effective for triglyceride reduction 1
   • Preferred over gemfibrozil due to lower risk of myopathy when combined with statins
   • Take fenofibrate in morning and statin in evening to minimize interaction risk 1

3. Third option: Consider omega-3 fatty acids (fish oil)

   • FDA-approved prescription products (not OTC supplements)
   • Can reduce triglycerides by approximately 45% in patients with severe hypertriglyceridemia 2
   • May be added to fenofibrate if triglycerides remain elevated 1

For Triglycerides ≥500 mg/dL:

1. First option: Add fibrate (fenofibrate preferred)

   • Primary target becomes triglyceride reduction to prevent pancreatitis 1
   • Fenofibrate dosage typically 54-160 mg daily 1

2. Second option: Add prescription omega-3 fatty acids

   • 4 grams daily dosing 2
   • Can be used in combination with fibrates for severe cases 1

Important Cautions and Monitoring

• Avoid gemfibrozil with statins due to higher myopathy risk compared to fenofibrate 1

• Niacin is generally not recommended despite its effectiveness:

  • May worsen glycemic control in diabetic patients 1
  • Has not shown cardiovascular benefit beyond statin therapy alone 1
  • Associated with increased risk of side effects including flushing and potential stroke risk 1

• Monitor for:

  • Muscle symptoms (myalgia, weakness) when combining statins with fibrates
  • Potential LDL-C elevation with fibrates or omega-3 fatty acids 2
  • Liver function tests with combination therapy

Special Considerations

• Higher doses of atorvastatin (40-80mg) may provide additional triglyceride lowering 1, 3 but should be reserved for patients with both high LDL and high triglycerides
• For patients with HIV on protease inhibitors, special dosing considerations apply when using statins with fibrates 1
• For severe hypertriglyceridemia (>1000 mg/dL), aggressive dietary fat restriction (<10% of calories) is necessary in addition to pharmacological therapy 1

Remember that the primary goal of therapy is to reduce cardiovascular risk and prevent pancreatitis in cases of severe hypertriglyceridemia.