Can I add VASCEPA to a patient's regimen who is already taking atorvastatin 20mg with elevated triglycerides?

Adding Vascepa to Atorvastatin for Elevated Triglycerides

For patients with elevated triglycerides (181 mg/dL) despite taking atorvastatin 20mg, adding icosapent ethyl (Vascepa) is reasonable to reduce cardiovascular risk and further lower triglyceride levels. 1

Assessment of Current Lipid Profile

The patient's current lipid profile shows:

• Total Cholesterol: 170 mg/dL (<200 mg/dL) - Normal
• HDL Cholesterol: 62 mg/dL (≥50 mg/dL) - Normal
• Triglycerides: 181 mg/dL (<150 mg/dL) - Elevated
• LDL Cholesterol: 80 mg/dL (<100 mg/dL) - Normal

While the patient's LDL-C is well-controlled on atorvastatin 20mg, the elevated triglyceride level represents residual cardiovascular risk that can be addressed.

Evidence Supporting Icosapent Ethyl Addition

The 2021 American Heart Association/American Stroke Association guideline specifically recommends icosapent ethyl for patients with elevated triglycerides who are already on statin therapy:

• For patients with triglycerides 135-499 mg/dL (patient has 181 mg/dL)
• On moderate or high-intensity statin therapy (patient is on atorvastatin 20mg)
• With LDL-C of 41-100 mg/dL (patient has LDL-C of 80 mg/dL)
• Treatment with icosapent ethyl 2g twice daily is reasonable 1

This recommendation is based on evidence showing that icosapent ethyl reduces major adverse cardiovascular events, including ischemic stroke, when added to statin therapy in patients with controlled LDL-C but elevated triglycerides.

Benefits of Adding Icosapent Ethyl

Adding icosapent ethyl to statin therapy has demonstrated:

• Reduction in major adverse cardiovascular events 1
• Significant triglyceride lowering effect
• In one case study, switching from omega-3-acid ethyl esters to icosapent ethyl resulted in a 41% reduction in triglyceride levels in a statin-treated patient with elevated triglycerides 2

Treatment Algorithm

1. Confirm persistent triglyceride elevation (>135 mg/dL despite statin therapy)
2. Verify LDL-C is controlled (41-100 mg/dL on statin therapy)
3. Add icosapent ethyl 2g twice daily
4. Recheck lipid panel in 4-12 weeks to assess response

Important Considerations

• Lifestyle modifications should continue to be emphasized (weight loss, exercise, limiting alcohol and refined carbohydrates)
• Icosapent ethyl is preferred over other omega-3 fatty acid preparations that contain both EPA and DHA
• Avoid combining fibrates with statins as this combination has not been shown to improve cardiovascular outcomes and may increase risk of myopathy 1
• Similarly, statin plus niacin combination therapy is not recommended as it has not shown additional cardiovascular benefit 1

Monitoring

• Monitor lipid profile 4-12 weeks after initiating icosapent ethyl 3
• Continue to monitor liver function and creatine kinase as clinically indicated while on statin therapy 3

By adding icosapent ethyl to the current atorvastatin regimen, you can address the patient's residual cardiovascular risk from elevated triglycerides while maintaining the LDL-lowering benefits of statin therapy.