What statin is best for treating hypertriglyceridemia?

From the Guidelines

For patients with hypertriglyceridemia, atorvastatin 20-40 mg daily would be the most appropriate statin therapy, as it has the strongest triglyceride-lowering effect among statins, typically reducing triglycerides by 20-40% 1.

Key Considerations

• The primary issue in hypertriglyceridemia is the elevated triglyceride level, rather than the LDL cholesterol level.
• Atorvastatin is preferred due to its strong triglyceride-lowering effect.
• Lifestyle modifications, such as reducing simple carbohydrate and alcohol intake, increasing physical activity, and possibly adding omega-3 fatty acid supplements (2-4 grams daily), are crucial in managing hypertriglyceridemia.
• Fibrates like fenofibrate could be considered as an alternative or add-on therapy if triglycerides remain above 500 mg/dL after statin treatment, as this level increases the risk of pancreatitis.

Treatment Approach

• Initial treatment should focus on lifestyle modifications and dietary counseling.
• For patients with severe hypertriglyceridemia, reduced intake of dietary fat and simple carbohydrates is recommended, in combination with drug treatment to reduce the risk of pancreatitis.
• Statins, such as atorvastatin, may be useful in modifying cardiovascular risk in patients with moderately elevated triglyceride levels.
• The addition of icosapent ethyl, a synthetic n-3 fatty acid preparation, to statin therapy may be considered in patients with ASCVD or diabetes and elevated triglycerides (135-499 mg/dL) to reduce cardiovascular risk 1.

Monitoring and Safety

• Regular monitoring of liver function tests and lipid panels is necessary to assess treatment efficacy and safety.
• The risk of pancreatitis should be considered in patients with severe hypertriglyceridemia, and treatment should be adjusted accordingly.

From the FDA Drug Label

The study included a 4-week dietary lead-in phase during which patients received rosuvastatin 10 mg daily, a cross-over phase that included two 6-week treatment periods with either rosuvastatin 20 mg or placebo in random order, followed by a 12-week open-label phase during which all patients received rosuvastatin 20 mg Table 16: Lipid-Modifying Effect of Rosuvastatin in Adult Patients with Primary Hypertriglyceridemia After Six Weeks by Median (Min, Max) Percent Change from Baseline to Week 6 Dose Placebo (n=26) Rosuvastatin 5 mg (n=25) Rosuvastatin 10 mg (n=23) Rosuvastatin 20 mg (n=27) Rosuvastatin 40 mg (n=25) Triglycerides 1 (-40,72) -21 (-58,38) -37 (-65,5) -37 (-72,11) -43 (-80, -7)

Rosuvastatin is effective in treating hypertriglyceridemia.

• The most effective dose of rosuvastatin for treating hypertriglyceridemia is 40 mg, which reduced triglycerides by -43%.
• Other doses of rosuvastatin, such as 5 mg, 10 mg, and 20 mg, also reduced triglycerides, but to a lesser extent. 2

From the Research

Statin Options for Hypertriglyceridemia

• Atorvastatin has been shown to reduce triglyceride levels in patients with hypertriglyceridemia, with dose-dependent reductions in total cholesterol, low density lipoprotein (LDL)-cholesterol and triglyceride levels observed in patients with hypercholesterolaemia and in patients with hypertriglyceridaemia 3.
• In comparative trials, atorvastatin produced greater reductions in total cholesterol, LDL-cholesterol, apolipoprotein B and triglyceride levels than lovastatin, pravastatin and simvastatin 3.
• Rosuvastatin has also been compared to atorvastatin in patients with hypercholesterolemia, with rosuvastatin showing a greater decrease in LDL cholesterol across the dose range, but atorvastatin showing a greater decrease in triglycerides at the 80mg dose 4.

Combination Therapy

• The addition of fenofibric acid to moderate-dose statin therapy has been shown to result in significant improvements in non-high-density lipoprotein cholesterol, apolipoprotein B, HDL-C, and triglycerides in patients with mixed dyslipidemia 5, 6.
• Fenofibric acid has also been shown to be effective in combination with atorvastatin, with improvements in HDL-C and triglyceride levels observed in patients with mixed dyslipidemia 6.

Comparative Efficacy

• Atorvastatin has been compared to fenofibrate in patients with familial combined hyperlipidemia, with atorvastatin showing greater efficacy in reaching lipid targets, but fenofibrate showing greater reductions in triglycerides and increases in HDL-C 7.
• The choice of statin for treating hypertriglyceridemia may depend on the individual patient's lipid profile and other factors, with atorvastatin and rosuvastatin being potential options 3, 4.