What is the next step in treatment for a patient with an LDL of 75 but elevated triglycerides of 200 while on Lipitor (Atorvastatin) 20mg?

Management of Elevated Triglycerides with Controlled LDL on Atorvastatin 20mg

For a patient with an LDL of 75 mg/dL but elevated triglycerides of 200 mg/dL while on Lipitor (atorvastatin) 20mg, the next step should be adding a fibrate such as fenofibrate or considering niacin therapy to specifically target the elevated triglycerides.

Assessment of Current Status

The patient has:

• Well-controlled LDL-C (75 mg/dL) - below target of <100 mg/dL
• Elevated triglycerides (200 mg/dL) - at the threshold requiring intervention
• Currently on moderate-dose atorvastatin (20mg)

Treatment Algorithm

Step 1: Evaluate Non-HDL-C

• Calculate non-HDL-C (Total cholesterol minus HDL-C)
• Target for non-HDL-C should be <130 mg/dL when triglycerides are 200-499 mg/dL 1

Step 2: Intensify Lifestyle Modifications

• Dietary changes:
  • Reduce saturated fat to <7% of total calories
  • Limit cholesterol to <200 mg/day
  • Reduce simple carbohydrate intake
  • Increase omega-3 fatty acids (2-4g/day) 1
• Physical activity: 30 minutes of moderate-intensity exercise most days
• Weight management: Target BMI 18.5-24.9 kg/m²
• Complete alcohol abstinence (particularly important for hypertriglyceridemia) 1

Step 3: Pharmacologic Intervention

Since LDL-C is at goal but triglycerides remain elevated at 200 mg/dL:

1. First-line pharmacologic option:

   • Add fibric acid derivative (fenofibrate preferred over gemfibrozil with statins) 1
   • Fenofibrate has lower risk of myopathy when combined with statins compared to gemfibrozil

2. Alternative option:

   • Add nicotinic acid (niacin) 1
   • Start with low dose (500mg daily) and gradually increase to minimize flushing
   • Monitor for potential worsening of glycemic control

Monitoring Recommendations

• Check lipid panel in 4-6 weeks after initiating combination therapy
• Monitor for muscle symptoms at each visit (risk of myopathy with statin-fibrate combination)
• Check liver enzymes 8-12 weeks after starting combination therapy
• Monitor blood glucose if niacin is chosen

Important Considerations and Cautions

• Risk of myopathy: The combination of statins and fibrates increases risk of myositis. Keep statin dose relatively low with this combination 1
• Gemfibrozil caution: Specifically avoid gemfibrozil with statins due to higher myopathy risk 1
• Renal function: Assess renal function before starting fibrates as they may increase serum creatinine
• Diabetes risk: Monitor glucose levels if using niacin as it may worsen glycemic control
• Prescription niacin: Dietary supplement niacin must not be used as a substitute for prescription niacin 1

Rationale for Recommendation

According to the American College of Cardiology/American Heart Association guidelines, when triglycerides are 200-499 mg/dL and LDL-C is at goal, the next target becomes non-HDL-C with a goal of <130 mg/dL 1. The recommended therapeutic options to achieve this goal include adding either niacin or fibrate therapy after LDL-C lowering has been achieved 1.

The patient's current atorvastatin dose has successfully controlled LDL-C but has not adequately addressed the hypertriglyceridemia, which is a common limitation of statin monotherapy. Fibrates or niacin can specifically target the elevated triglycerides while maintaining the LDL-lowering effect of the statin 1.