What is the best statin for a patient with high LDL and hypertriglyceridemia, and no allergies?

Best Statin for LDL >100 mg/dL and Triglycerides >150 mg/dL

Start with a high-intensity statin—specifically atorvastatin 40-80 mg or rosuvastatin 20-40 mg—as these agents provide the most potent LDL-lowering (≥50% reduction) and have superior triglyceride-lowering effects at higher doses compared to other statins. 1, 2

Primary Recommendation: High-Intensity Statin Therapy

For patients with LDL >100 mg/dL and triglycerides >150 mg/dL, the treatment priority is dual:

• First-line therapy is a high-intensity statin to achieve an LDL goal of <70 mg/dL (<1.8 mmol/L), which requires ≥50% reduction from baseline 1, 2
• High-intensity statins are defined as atorvastatin 40-80 mg or rosuvastatin 20-40 mg 1

Why High-Intensity Statins for Combined Dyslipidemia

The combination of elevated LDL and triglycerides represents combined hyperlipidemia, which requires aggressive LDL reduction as the primary target while simultaneously addressing triglycerides 1:

• Atorvastatin and rosuvastatin at higher doses provide dose-dependent triglyceride reductions of 22-45% in patients with baseline triglycerides >250 mg/dL 3, 4
• All statins reduce triglycerides proportionally to their LDL-lowering potency, with a triglyceride/LDL cholesterol ratio of approximately 0.5-1.2 depending on baseline triglyceride levels 4
• Higher-dose statins (atorvastatin 40-80 mg) are moderately effective at reducing triglycerides in hypertriglyceridemic patients who also have elevated LDL 1

Specific Statin Selection

Atorvastatin is the preferred choice for several reasons:

• Atorvastatin 40-80 mg provides 48-52% LDL reduction 5
• At doses of 20-80 mg, atorvastatin significantly increases LDL particle size and decreases small dense LDL (the atherogenic subclass associated with hypertriglyceridemia) 3
• Atorvastatin demonstrates superior triglyceride-lowering compared to equivalent LDL-lowering doses of other statins 3, 4

Rosuvastatin 20-40 mg is an equally valid alternative:

• Rosuvastatin 20 mg provides approximately 52% LDL reduction, and 40 mg provides 55-63% reduction 6
• Rosuvastatin significantly reduces triglycerides and increases HDL-C in patients with mixed dyslipidemia 6
• In the JUPITER trial, rosuvastatin 20 mg reduced cardiovascular events by 44% in patients with elevated inflammatory markers 6

Treatment Algorithm

1. Initiate atorvastatin 40 mg or rosuvastatin 20 mg immediately (do not delay for lifestyle changes alone in patients with LDL >100 mg/dL) 2

2. Reassess lipid panel at 4-12 weeks 1, 2:

   • If LDL goal of <70 mg/dL is not achieved, increase to atorvastatin 80 mg or rosuvastatin 40 mg
   • If triglycerides remain >150 mg/dL despite statin therapy, consider adding adjunctive therapy

3. For persistent hypertriglyceridemia (>150 mg/dL) on maximally tolerated statin 2:

   • Add fenofibrate 145-200 mg daily (preferred over gemfibrozil due to lower myopathy risk with statins) 1, 2
   • Alternative: icosapent ethyl 2-4 g daily 2

4. If LDL remains ≥70 mg/dL on maximum statin therapy, add ezetimibe 10 mg daily 1, 2

Critical Pitfalls to Avoid

• Do not use moderate-intensity statins (atorvastatin 10-20 mg, rosuvastatin 5-10 mg) as initial therapy in patients with both elevated LDL and triglycerides, as this represents higher cardiovascular risk requiring aggressive treatment 1, 2

• Avoid gemfibrozil in combination with any statin due to significantly increased myopathy risk; fenofibrate is safer for combination therapy 1

• Do not use niacin in combination with statins—the FDA withdrew approval for this combination in 2016 due to unfavorable benefit-risk profile and lack of cardiovascular benefit 2, 7

• Never delay statin initiation waiting for lifestyle changes alone when LDL is >100 mg/dL and triglycerides are elevated, as this increases cardiovascular risk 2

Monitoring Requirements

• Measure hepatic aminotransferases before starting therapy and monitor if risk factors for hepatotoxicity exist 1
• Check creatine kinase only if musculoskeletal symptoms develop 1
• Recheck lipid panel at 4-12 weeks, then every 6-12 months once goals are achieved 1