What is the next step in managing a patient with a history of anal cancer, Human Immunodeficiency Virus (HIV) infection, and Hyperlipidemia (HLD), who has hypertriglyceridemia, elevated total cholesterol, low High-Density Lipoprotein (HDL) cholesterol, and elevated Low-Density Lipoprotein (LDL) cholesterol, with a 20.1% Atherosclerotic Cardiovascular Disease (ASCVD) risk?

From the Guidelines

The next step in management for this patient is to initiate high-intensity statin therapy, specifically atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily, as recommended by the 2018 American Heart Association/American College of Cardiology/Multisociety Cholesterol Guideline 1. The patient has multiple risk factors including HIV, hypertension, and a high ASCVD risk score of 20.1%, placing them in a very high-risk category. Their lipid panel shows significant hypertriglyceridemia and low HDL, both of which contribute to cardiovascular risk. While the LDL is below 100 mg/dL, the overall risk profile warrants aggressive lipid management. In addition to statin therapy, the patient should be counseled on lifestyle modifications including:

• a Mediterranean or DASH diet
• regular physical activity
• smoking cessation if applicable
• limiting alcohol consumption For the elevated triglycerides, consider adding fenofibrate 145 mg daily if levels remain above 500 mg/dL after statin therapy and lifestyle changes, as suggested by the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol 1. Close monitoring of liver function tests and creatine kinase is necessary when initiating statin therapy, particularly in patients with HIV who may be on antiretroviral medications that can interact with statins, as noted in the 2018 cholesterol clinical practice guidelines 1. Reassess lipid levels in 4-12 weeks after starting therapy to evaluate response and adjust treatment as needed.

From the FDA Drug Label

Ezetimibe tablets is indicated ... as an adjunct to diet to reduce elevated LDL-C in adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH)

When ezetimibe tablets is used in combination with a statin, fenofibrate, or other LDL-C lowering therapies, refer to the Prescribing Information of these products for information on the safe and effective use

The next step in managing a patient with a history of anal cancer, Human Immunodeficiency Virus (HIV) infection, and Hyperlipidemia (HLD), who has hypertriglyceridemia, elevated total cholesterol, low High-Density Lipoprotein (HDL) cholesterol, and elevated Low-Density Lipoprotein (LDL) cholesterol, with a 20.1% Atherosclerotic Cardiovascular Disease (ASCVD) risk is to consider initiating or adjusting lipid-lowering therapy, such as ezetimibe, in combination with a statin or other LDL-C lowering therapies, as an adjunct to diet, to reduce elevated LDL-C levels.

• The patient's elevated LDL-C and high ASCVD risk suggest the need for aggressive lipid management.
• Ezetimibe may be considered as part of the treatment plan, but its use should be guided by the patient's specific clinical profile and medical history, including their HIV status and history of anal cancer.
• It is essential to monitor the patient's liver enzymes and muscle symptoms while on ezetimibe therapy, especially if used in combination with a statin or other LDL-C lowering therapies 2.

From the Research

Managing a Patient with a History of Anal Cancer, HIV Infection, and Hyperlipidemia

The patient in question has a complex medical history, including anal cancer, HIV infection, and hyperlipidemia, with specific lipid profile abnormalities such as hypertriglyceridemia, elevated total cholesterol, low High-Density Lipoprotein (HDL) cholesterol, and elevated Low-Density Lipoprotein (LDL) cholesterol, alongside a calculated 20.1% Atherosclerotic Cardiovascular Disease (ASCVD) risk.

Current Guidelines and Recommendations

• The management of such a patient involves a multifaceted approach, considering the reduction of ASCVD risk as a primary goal.
• According to 3, 4, 5, statins are the first-line therapy for reducing LDL cholesterol levels and ASCVD risk.
• For patients who cannot achieve target LDL-C levels with statin monotherapy or have statin-associated adverse effects, combination therapy with ezetimibe is recommended 3, 4.
• Ezetimibe, a cholesterol absorption inhibitor, can lead to additional LDL-C reduction and decreased ASCVD risk when added to statin therapy, without significant safety concerns 3, 4.
• For very high-risk patients or those who cannot tolerate statins, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors may be considered as they significantly decrease serum LDL cholesterol levels and ASCVD risks 3, 6.

Treatment Considerations

• Given the patient's high ASCVD risk (20.1%), the use of high-intensity statins is recommended, aiming for an LDL-C reduction of 50% or greater 5, 7.
• If high-intensity statin treatment is not tolerated, combining a moderate-intensity statin with ezetimibe is a reasonable approach 5.
• The choice and dose of statin can impact the percentage of LDL-C reduction and the achievement of a ≥50% reduction in LDL-C, making it crucial for clinicians to select the most appropriate treatment for individual patients 7.

Additional Therapies

• PCSK9 inhibitors have been shown to lower LDL-C levels substantially and reduce ASCVD risk in very high-risk patients or those not receiving statins 3, 6.
• The decision to use PCSK9 inhibitors or ezetimibe should be based on the patient's specific clinical profile, including statin tolerance and the presence of very high ASCVD risk factors 6.