What is the best course of treatment for a 44-year-old male with hypercholesterolemia (elevated fasting cholesterol), low high-density lipoprotein (HDL) cholesterol, and elevated creatine kinase (CK) levels?

Management of Hypercholesterolemia with Elevated CK in a 44-Year-Old Male

This patient requires statin therapy to achieve an LDL-C target of <100 mg/dL (2.6 mmol/L), with careful monitoring for statin-associated muscle toxicity given the baseline elevated CK.

Risk Stratification and Treatment Targets

This patient's lipid panel reveals:

• Total cholesterol: 5.8 mmol/L (224 mg/dL) - above optimal 1
• LDL-C: 3.7 mmol/L (143 mg/dL) - elevated 1
• HDL-C: 1.7 mmol/L (66 mg/dL) - actually above the low threshold despite being flagged 1
• Non-HDL-C: 4.1 mmol/L (158 mg/dL) - above target 1

Risk assessment using Framingham scoring is essential to determine treatment intensity 1. For a 44-year-old male with these lipid values, assuming no smoking, diabetes, or hypertension based on the normal labs provided, he would accumulate points as follows: age 40-44 years = 0 points, total cholesterol 200-239 mg/dL = 8 points, HDL ≥60 mg/dL = -1 point, yielding a 10-year CHD risk of approximately 1-2% 1.

With 0-1 risk factors and 10-year risk <10%, his LDL-C goal is <160 mg/dL (4.15 mmol/L) 1. However, more recent guidelines suggest targeting LDL-C <130 mg/dL (3.4 mmol/L) for moderate risk patients, or achieving at least a 50% reduction from baseline 1.

Statin Therapy Recommendation

Initiate moderate-intensity statin therapy (e.g., atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily) 1. This approach balances efficacy with the patient's baseline elevated CK of 237 IU/L (reference range 38-204 IU/L) 2.

• Moderate-intensity statins reduce LDL-C by approximately 30-50%, which would bring this patient's LDL-C from 143 mg/dL to approximately 72-100 mg/dL, achieving guideline targets 1
• Starting with moderate rather than high-intensity therapy is prudent given the baseline CK elevation, as high-dose statins (atorvastatin 80 mg) carry higher risk of muscle-related adverse effects 2

Critical Consideration: Elevated Creatine Kinase

The baseline CK of 237 IU/L represents a mild elevation (approximately 1.2 times the upper limit of normal) 2.

Before initiating statin therapy:

• Document baseline CK level (already done) 2
• Assess for secondary causes of CK elevation: recent strenuous exercise, intramuscular injections, trauma, hypothyroidism (TSH normal in this patient), or other medications 2
• The patient's thyroid function, liver enzymes (AST 20, ALT 24), and renal function (creatinine 75 μmol/L) are all normal, which is reassuring 2

Statin therapy is NOT contraindicated with this degree of CK elevation 2. According to FDA labeling data, statins can be initiated when baseline CK is <5-10 times the upper limit of normal in asymptomatic patients 2.

Monitoring Strategy

Initial monitoring (first 3 months):

• Repeat lipid panel at 4-12 weeks after statin initiation to assess response 1, 3
• Check CK and liver enzymes (ALT) only if patient develops muscle symptoms (pain, weakness, tenderness) 2, 3
• Routine CK monitoring in asymptomatic patients is NOT recommended and may lead to unnecessary discontinuation 3

Long-term monitoring:

• Annual lipid panel to ensure target maintenance 3, 4
• CK measurement only if myalgia develops 3
• Annual ALT only if clinically indicated 2

Management of Statin-Associated Muscle Symptoms

If myalgia develops during treatment:

• Measure CK level immediately 2
• If CK >10 times ULN (>2040 IU/L): discontinue statin immediately due to rhabdomyolysis risk 2
• If CK 3-10 times ULN with symptoms: hold statin, recheck CK in 2-4 weeks 2
• If CK <3 times ULN with mild symptoms: consider dose reduction or switch to alternate statin 2

Alternative strategies if statin intolerance occurs:

• Try different statin (rosuvastatin, pravastatin, or fluvastatin may have different tolerability profiles) 1
• Reduce dosing frequency (alternate day or twice weekly dosing) 1
• Add ezetimibe 10 mg daily (reduces LDL-C by approximately 18-20%) 1

Additional Lipid Management

The low red cell folate (280 nmol/L, reference 340-1474.7) warrants attention as it may contribute to cardiovascular risk through elevated homocysteine, though this is not a primary treatment target 1.

Basophil elevation (2.7%, absolute count 0.18 x10^9/L) is noted but unlikely related to lipid management; consider evaluation for allergic conditions or myeloproliferative disorders if persistent, though this is outside the scope of cholesterol management 1.

Common Pitfalls to Avoid

• Do not delay statin therapy due to mildly elevated baseline CK in an asymptomatic patient 2, 3
• Do not routinely monitor CK in asymptomatic patients on statins, as this leads to unnecessary treatment discontinuation 3
• Do not use HDL-C as a treatment target; it is a risk marker only 1, 4
• Do not calculate LDL-C using Friedewald equation when triglycerides are >400 mg/dL (not applicable here as TG = 0.9 mmol/L = 80 mg/dL) 4
• Do not stop statins for transient CK elevations <3 times ULN without symptoms 2

Therapeutic Lifestyle Changes

Concurrent with statin initiation, implement:

• Reduce saturated fat intake to <7% of total calories 1
• Increase dietary fiber (10-25 g/day soluble fiber) 1
• Add plant stanols/sterols (2 g/day) 1
• Achieve/maintain healthy weight (current BMI appears normal based on albumin and general health markers) 1
• Regular aerobic exercise (≥30 minutes most days) 1