What medication is indicated for a patient with hypercholesterolemia, hypertriglyceridemia, and low HDL?

Treatment for Mixed Dyslipidemia with Elevated LDL, Elevated Triglycerides, and Low HDL

For this patient with LDL 153 mg/dL, triglycerides 309 mg/dL, and HDL 32 mg/dL, a high-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) should be initiated as first-line therapy, with consideration of adding fenofibrate if triglycerides remain elevated after statin optimization.

Assessment of Lipid Profile

The patient presents with:

• Total cholesterol: 243 mg/dL (high)
• LDL cholesterol: 153 mg/dL (high)
• Triglycerides: 309 mg/dL (high)
• HDL cholesterol: 32 mg/dL (low)
• VLDL cholesterol: 58 mg/dL (high)

This represents a mixed dyslipidemia pattern with all three major abnormalities:

1. Elevated LDL-C (>99 mg/dL)
2. Elevated triglycerides (>149 mg/dL)
3. Low HDL-C (<39 mg/dL)

Treatment Algorithm

Step 1: Statin Therapy

• Begin with a high-intensity statin as first-line therapy 1
  • Atorvastatin 40-80 mg daily OR
  • Rosuvastatin 20-40 mg daily
• This approach targets the elevated LDL-C and will also have moderate effects on triglycerides

Step 2: Evaluate Response (after 4-6 weeks)

• If LDL-C reduced to goal (<100 mg/dL) but triglycerides remain >200 mg/dL:
  • Add fenofibrate 1, 2
• If LDL-C not at goal:
  • Optimize statin dose to maximum tolerated
  • Consider adding ezetimibe if needed

Step 3: Address Low HDL-C

• If HDL-C remains <40 mg/dL after optimizing statin and triglyceride therapy:
  • Consider fenofibrate (if not already added) 1
  • Lifestyle modifications (exercise, smoking cessation)

Rationale for Recommendation

1. High-intensity statin as foundation therapy:

   • Will reduce LDL-C by approximately 50% 3, 4
   • Will also reduce triglycerides by 20-40% when baseline triglycerides are elevated 5
   • Guidelines consistently recommend statins as first-line therapy for elevated LDL-C 1

2. Addition of fenofibrate for persistent hypertriglyceridemia:

   • Indicated for patients with triglycerides >200 mg/dL despite statin therapy 1
   • FDA-approved for hypertriglyceridemia and mixed dyslipidemia 2
   • Helps raise HDL-C levels 1

Important Considerations and Cautions

• Monitor for myopathy risk: The combination of statins with fibrates (especially gemfibrozil) increases risk of myositis 1

  • Fenofibrate has lower interaction risk than gemfibrozil
  • Check creatine kinase if muscle symptoms develop
  • Start with lower doses in patients with renal impairment 2

• Glycemic control: If patient has diabetes, improving glycemic control should be part of the treatment strategy as it can help reduce triglyceride levels 1

• LDL goal: For most patients with mixed dyslipidemia, the target LDL-C is <100 mg/dL 1

  • More intensive LDL lowering (<70 mg/dL) may be appropriate for very high-risk patients 1

• Lifestyle modifications: Should be implemented alongside pharmacotherapy:

  • Weight loss if overweight
  • Reduced intake of saturated fats and simple carbohydrates
  • Increased physical activity
  • Limitation of alcohol consumption 1

This approach prioritizes reducing cardiovascular morbidity and mortality by addressing all components of this patient's mixed dyslipidemia, with emphasis on the most effective evidence-based interventions.