What treatment is recommended for a patient with hypercholesterolemia (elevated total cholesterol), hypertriglyceridemia (elevated triglycerides), low high-density lipoprotein (HDL) cholesterol, and elevated low-density lipoprotein (LDL) cholesterol?

Treatment Recommendation for Mixed Dyslipidemia

Start a high-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) immediately to target LDL <100 mg/dL, with consideration for adding niacin or fenofibrate if triglycerides remain elevated after achieving LDL control.

Primary Treatment: Statin Therapy

Your lipid panel shows multiple high-risk features requiring aggressive intervention. Statins are the first-line agents for this mixed dyslipidemia pattern because they address the elevated LDL (158 mg/dL) while also providing moderate triglyceride reduction and modest HDL elevation 1.

Statin Selection and Dosing

• High-intensity statin therapy is indicated given your LDL is 158 mg/dL (goal <100 mg/dL, ideally <70 mg/dL for very high-risk patients) 1
• Atorvastatin 40-80 mg daily is preferred because higher doses provide approximately 40-50% LDL reduction, which would bring your LDL from 158 mg/dL to approximately 79-95 mg/dL 1, 2, 3
• Atorvastatin also reduces triglycerides by 20-30% at higher doses, addressing your elevated triglycerides (233 mg/dL) 1, 2, 4
• Start with atorvastatin 40 mg daily, then titrate to 80 mg if LDL goal not achieved after 4-6 weeks 1

Secondary Considerations: Addressing Low HDL and High Triglycerides

When to Add Combination Therapy

After achieving LDL control with statin monotherapy, if HDL remains <40 mg/dL or triglycerides remain >200 mg/dL, consider adding:

Niacin (extended-release) as the preferred second agent 1:

• Start at 500 mg at bedtime with low-fat snack 5
• Titrate by 500 mg every 4 weeks to maintenance dose of 1000-2000 mg daily 5
• Niacin raises HDL by 15-35% and lowers triglycerides by 20-50% 1, 5
• Caution: Monitor for flushing (take with food, avoid alcohol/hot beverages), hyperglycemia, and liver function 5
• Restrict to ≤2 g/day if diabetic 1

Alternative: Fenofibrate 1:

• Consider if niacin not tolerated or if patient is diabetic with very high triglycerides
• Particularly effective when triglycerides >200 mg/dL and HDL <40 mg/dL 1
• Monitor carefully for myopathy risk when combining with statins; fenofibrate is safer than gemfibrozil with statins 1

Treatment Algorithm

1. Weeks 0-4: Start atorvastatin 40 mg daily at bedtime
2. Week 4-6: Check lipid panel
   • If LDL >100 mg/dL: Increase to atorvastatin 80 mg daily 1
   • If LDL <100 mg/dL but triglycerides >200 mg/dL or HDL <40 mg/dL: Consider adding niacin 1
3. Week 8-12: Recheck lipids on optimized statin dose
4. Week 12+: If combination therapy needed, initiate niacin titration starting at 500 mg 5

Lifestyle Modifications (Concurrent with Pharmacotherapy)

Do not delay statin therapy for lifestyle changes alone given your LDL >130 mg/dL 1:

• Reduce saturated fat to <7% of calories 1
• Add plant stanols/sterols (2 g/day) 1
• Aerobic exercise 30+ minutes most days 1
• Weight loss if overweight (improves all lipid parameters) 1
• Smoking cessation (can raise HDL by up to 30%) 1

Monitoring

• Lipid panel at 4-6 weeks after starting or changing statin dose 1
• Liver enzymes (ALT/AST) at baseline and if symptoms develop 1
• Creatine kinase (CK) only if muscle symptoms occur 1
• Once at goal: recheck lipids every 6-12 months 1

Critical Safety Considerations

• Avoid gemfibrozil-statin combinations due to high myopathy risk; fenofibrate is safer if fibrate needed 1
• Watch for myalgia, muscle weakness, or dark urine (signs of myopathy/rhabdomyolysis) 1
• Statin therapy has proven mortality benefit in long-term studies, with excellent safety profile when monitored appropriately 1, 5