From the Guidelines
For a 61-year-old woman with triglycerides of 450 mg/dL, total cholesterol of 250 mg/dL, and LDL of 120 mg/dL, I recommend starting with a statin to lower LDL-C to a goal of 100 mg/dL, as well as lifestyle modifications to reduce triglycerides and non-HDL-C. According to the AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease 1, the goal for LDL-C is 100 mg/dL, and further reduction to 70 mg/dL is reasonable.
Lipid Management
The patient's lipid profile indicates a need for lipid-lowering therapy, with a focus on reducing LDL-C and non-HDL-C. The guidelines recommend starting dietary therapy, reducing intake of saturated fats, trans-fatty acids, and cholesterol, and promoting daily physical activity and weight management 1.
Treatment Options
For patients with triglycerides between 200-499 mg/dL, non-HDL-C should be 130 mg/dL, and further reduction to 100 mg/dL is reasonable 1. Therapeutic options to reduce non-HDL-C include more intense LDL-C–lowering therapy, niacin, or fibrate therapy after LDL-C–lowering therapy. Given the patient's triglyceride level of 450 mg/dL, a combination of a statin and a fibrate or omega-3 fatty acids may be necessary to achieve the desired reduction in triglycerides and non-HDL-C.
Lifestyle Modifications
Lifestyle modifications are essential and should include a low-carbohydrate diet, moderate alcohol consumption or abstinence, regular exercise, and weight loss if overweight. The patient should also be screened for secondary causes of hypertriglyceridemia, including diabetes, hypothyroidism, kidney disease, and medications like estrogens or corticosteroids.
Monitoring
Treatment should be monitored with lipid panels every 6-12 weeks initially until target levels are achieved, then every 6-12 months. Liver function tests should be checked before starting therapy and periodically thereafter to monitor for medication side effects.
From the FDA Drug Label
Fenofibrate tablets are indicated as adjunctive therapy to diet to reduce elevated low-density lipoprotein cholesterol (LDL-C), total cholesterol (Total-C), Triglycerides and apolipoprotein B (Apo B), and to increase high-density lipoprotein cholesterol (HDL-C) in adult patients with primary hypercholesterolemia or mixed dyslipidemia. The initial dose of fenofibrate tablet is 160 mg once daily for primary hypercholesterolemia or mixed dyslipidemia. For severe hypertriglyceridemia, the initial dose is 54 mg per day to 160 mg per day.
The patient has elevated triglycerides (450 mg/dL) and high LDL (120 mg/dL). Based on the drug label, fenofibrate can be used as an adjunct to diet to reduce triglycerides, LDL-C, and total cholesterol, and increase HDL-C.
- The recommended initial dose for primary hypercholesterolemia or mixed dyslipidemia is 160 mg once daily.
- For severe hypertriglyceridemia, the initial dose is 54 mg per day to 160 mg per day. Given the patient's triglyceride level of 450 mg/dL, which falls under severe hypertriglyceridemia, the initial dose could be 54 mg per day to 160 mg per day. However, considering the patient also has high LDL, the dose for primary hypercholesterolemia or mixed dyslipidemia might be more appropriate, which is 160 mg once daily. It's crucial to monitor the patient's lipid levels and adjust the dosage as necessary to achieve the desired therapeutic effect while minimizing potential side effects 2.
From the Research
Treatment Options for Hyperlipidemia
The patient's condition, with triglycerides of 450, total cholesterol 250, and LDL 120, can be classified as mixed hyperlipidemia. According to the studies, combination therapy with a statin and a fibrate may be more effective in managing this condition than monotherapy with either drug alone 3, 4, 5, 6.
Efficacy of Combination Therapy
- The study by 3 found that combination therapy with low-dose atorvastatin and fenofibrate resulted in a significant decrease in LDL, triglycerides, and total cholesterol, and a significant increase in HDL.
- The study by 5 compared the efficacy of atorvastatin alone and in combination with fenofibrate in type 2 diabetes mellitus patients with hyperlipidemia, and found that the combination therapy resulted in a greater reduction in triglycerides, total cholesterol, and LDL cholesterol.
- The study by 6 evaluated the efficacy and safety of ABT-335 (fenofibric acid) in combination with atorvastatin in patients with mixed dyslipidemia, and found that the combination therapy resulted in significantly greater improvements in triglycerides, HDL cholesterol, and LDL cholesterol compared to monotherapy with either drug alone.
Safety Profile of Combination Therapy
- The study by 3 found that the combination therapy with low-dose atorvastatin and fenofibrate had a similar safety profile to monotherapy with either drug alone.
- The study by 6 found that the combination therapy with ABT-335 and atorvastatin was generally well tolerated, with a safety profile consistent with those of ABT-335 and atorvastatin monotherapies.
High-Intensity Statins
- The study by 7 recommends the use of high-intensity statins for patients at high risk for atherosclerotic cardiovascular disease, with a goal of reducing LDL cholesterol by 50% or greater.
- However, this study does not specifically address the use of combination therapy with a statin and a fibrate in patients with mixed hyperlipidemia.