What is the diagnosis for a 24-year-old Hispanic male with hypercholesterolemia (elevated total cholesterol) and high Low-Density Lipoprotein (LDL) levels, presenting with a history of anabolic steroid use?

From the Guidelines

This patient requires immediate intervention for severe hypercholesterolemia, likely exacerbated by anabolic steroid use, and I recommend starting high-intensity statin therapy with atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily, as suggested by the 2016 ESC/EAS guidelines for the management of dyslipidaemias 1. The patient's LDL-C level of 265 mg/dL is significantly elevated, and according to the guidelines, LDL-C should be used as the primary lipid analysis for screening, risk estimation, diagnosis, and management 1. Given the patient's age and severely elevated LDL-C level, familial hypercholesterolemia should be suspected, and the patient should be evaluated for this condition 1. The patient should discontinue anabolic steroids immediately, as they significantly worsen lipid profiles by decreasing HDL and increasing LDL. Lifestyle modifications are essential, including a Mediterranean or DASH diet low in saturated fats, regular aerobic exercise (150 minutes weekly), weight management if needed, and avoiding alcohol. Follow-up lipid panel testing should occur in 4-12 weeks to assess treatment response. If inadequate improvement occurs with statins alone, adding ezetimibe 10mg daily may be necessary, as the patient's extremely elevated LDL puts him at high risk for premature cardiovascular disease. The European Society of Cardiology guidelines recommend measuring Lipoprotein(a) in patients at high risk of cardiovascular disease, but the primary focus should be on reducing the patient's LDL-C level to < 100 mg/dL, or a reduction of at least 50% if the baseline LDL-C is between 100 and 200 mg/dL, as recommended for patients at high CV risk 1.

From the FDA Drug Label

The changes in lipid endpoints after an additional 48 weeks of treatment with ezetimibe tablet coadministered with fenofibrate or with fenofibrate alone were consistent with the 12-week data displayed above Ezetimibe Tablet coadministered with fenofibrate significantly lowered total-C, LDL-C, Apo B, and non-HDL-C compared to fenofibrate administered alone TABLE 12: Response to Ezetimibe Tablet and Fenofibrate Initiated Concurrently in Patients with Mixed Hyperlipidemia (Mean % Change from Untreated Baseline* at 12 weeks) Treatment (Daily Dose) N Total-C LDL-C Apo B Non-HDL-C Placebo 63 0 0 -1 0 Ezetimibe Tablet 185 -12 -13 -11 -15 Fenofibrate 160 mg 188 -11 -6 -15 -16 Ezetimibe Tablet + Fenofibrate 160 mg 183 -22 -20 -26 -30

The patient has high cholesterol with an LDL of 265 and a history of anabolic steroid use.

• Ezetimibe may be considered as part of the treatment plan to lower LDL-C.
• The patient's LDL level is higher than the mean baseline LDL-C value in the HeFH trial.
• Combination therapy with ezetimibe and fenofibrate may be effective in lowering LDL-C, as shown in the mixed hyperlipidemia trial.
• However, the patient's specific situation, including the history of anabolic steroid use, is not directly addressed in the provided drug label information 2.

From the Research

Patient Profile

• 24-year-old Hispanic male
• Cholesterol level: 328
• LDL: 265
• HDL: 43
• History of anabolic steroids

Treatment Options

• Statins are first-line therapy for treating dyslipidemia, but may not be sufficient in decreasing LDL cholesterol levels 3
• Ezetimibe, a cholesterol absorption inhibitor, can lead to additional LDL cholesterol reduction and decreased ASCVD risk when added to statin therapy 3
• Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, such as alirocumab and evolocumab, can significantly decrease serum LDL cholesterol levels and ASCVD risks when added to maximally tolerated statin therapy 3
• Bempedoic acid, a newly approved agent, reduces hepatic cholesterol synthesis and can be used in combination with other agents to lower LDL-C levels 4, 5

Lifestyle Modifications

• Physical activity is a critical component of first-line treatment for elevated blood pressure or cholesterol, and can improve both blood pressure and blood cholesterol 6
• Increasing physical activity has extensive benefits, including improving blood pressure and blood cholesterol, and can be prescribed as a lifestyle behavior treatment option for all patients, including those with mild-moderate-risk patients with elevated blood pressure and blood cholesterol 6

LDL-Cholesterol Reduction

• The percentage LDL-C reduction with statins, ezetimibe, and PCSK9 inhibition is not attenuated in patients starting with lower baseline LDL-C levels, and is 6.6% greater for PCSK9 inhibition 7
• Evolocumab, a PCSK9 inhibitor, can achieve a higher percentage reduction in LDL-C levels in patients with lower baseline LDL-C levels, ranging from 59.4% to 66.1% 7