What is the best approach to manage hyperlipidemia in an obese 61-year-old female with hypertension (HTN), who has elevated total cholesterol, triglycerides, and low-density lipoprotein (LDL) cholesterol, and has stopped taking rosuvastatin (generic name: rosuvastatin) due to side effects?

Management of Hyperlipidemia in a Statin-Intolerant Patient

Given this patient's statin intolerance without muscle symptoms, I recommend reinitiating rosuvastatin at a lower dose of 5 mg daily, as this represents the most effective evidence-based approach to reduce her cardiovascular risk, with the option to add ezetimibe if LDL-C goals are not achieved. 1

Risk Stratification and Treatment Goals

This 61-year-old obese female with hypertension requires aggressive lipid management:

• Current lipid profile indicates high cardiovascular risk: Total cholesterol 235 mg/dL, LDL-C 154 mg/dL, triglycerides 219 mg/dL, HDL-C 41 mg/dL 1
• Target LDL-C should be <100 mg/dL for primary prevention in patients with multiple risk factors (obesity, hypertension, elevated triglycerides, low HDL-C) 1
• Non-HDL-C target should be <130 mg/dL (currently 194 mg/dL, calculated as total cholesterol minus HDL-C) 1

Addressing Statin Intolerance

Key Clinical Consideration

The patient reports feeling "bad" on rosuvastatin but denies muscle soreness, which is critical—this suggests her intolerance may not be true statin-related myopathy 2

Recommended Statin Rechallenge Strategy

Start with rosuvastatin 5 mg once daily: 2

• This lower dose reduces LDL-C by 42-52% while minimizing side effects 3, 4
• Rosuvastatin 5 mg is more effective than initial doses of other statins (atorvastatin 10 mg, simvastatin 20 mg) 3
• The 5 mg dose has excellent tolerability with rare myopathy risk 5, 4
• For obese patients specifically, rosuvastatin 5 mg maintains efficacy 3

Alternative Statin Options if Rosuvastatin Cannot Be Tolerated

Consider pitavastatin as an alternative: 1

• In patients with obesity and metabolic disorders, pitavastatin may be protective against new-onset diabetes
• When combined with ezetimibe, can reduce LDL-C by up to 47% 1

Combination Therapy Approach

If LDL-C Goal Not Achieved with Statin Alone

Add ezetimibe 10 mg daily: 1

• Provides additional 15-20% LDL-C reduction
• Excellent safety profile with minimal drug interactions
• Should be added if LDL-C remains ≥100 mg/dL after 4-6 weeks of statin therapy 1

For Persistent Hypertriglyceridemia

Address triglycerides (currently 219 mg/dL) after optimizing LDL-C: 1

• First-line approach: Intensive lifestyle modification including weight loss, reduced simple carbohydrates, and increased physical activity 1
• Consider fibrate therapy (fenofibrate preferred over gemfibrozil due to lower drug interaction risk with statins) if triglycerides remain >200 mg/dL after LDL-C optimization 1
• Omega-3 fatty acids may be considered as adjunctive therapy 1

Critical Lifestyle Interventions

Weight Management Priority

ALLI (orlistat) alone is insufficient: 1

• Recommend comprehensive weight reduction program targeting BMI <25 kg/m² and waist circumference <35 inches 1
• Weight loss of 5-10% can significantly improve lipid profile and reduce triglycerides 1

Dietary Modifications

Implement therapeutic lifestyle changes: 1

• Saturated fat <7% of calories, cholesterol <200 mg/day 1
• Increase intake of fruits, vegetables, whole grains, and lean proteins 1
• Limit simple carbohydrates to address hypertriglyceridemia 1

Monitoring Strategy

Reassess lipid panel in 4-6 weeks: 1, 2

• Check LDL-C, non-HDL-C, and triglycerides
• Assess for any muscle symptoms or adverse effects
• Consider liver enzyme testing if clinically indicated 2

If patient reports side effects again:

• Distinguish between true statin intolerance versus nocebo effect 1
• Consider every-other-day dosing or alternative-day statin therapy
• If confirmed intolerance, proceed with ezetimibe monotherapy or bempedoic acid (if available) 1

Blood Pressure Optimization

Continue amlodipine for hypertension: 1

• Calcium channel blockers do not adversely affect lipid profiles 6
• Target blood pressure <140/90 mm Hg (or <130/80 mm Hg if tolerated) 1

Common Pitfalls to Avoid

• Do not abandon statin therapy based on vague symptoms without objective evidence of myopathy (no CK elevation, no muscle pain) 2
• Avoid gemfibrozil if using statins due to increased myopathy risk; fenofibrate is safer 2
• Do not treat triglycerides before optimizing LDL-C in this patient 1
• Ensure patient understands cardiovascular risk to improve adherence—her 10-year risk is substantially elevated with multiple risk factors 1