What is the treatment for a 34-year-old male with hypercholesterolemia and hypertriglyceridemia?

Treatment for a 34-Year-Old Male with Total Cholesterol 260 mg/dL and Triglycerides 247 mg/dL

Initiate moderate-intensity statin therapy immediately (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily) as first-line treatment, which will address both the elevated LDL-C and provide 10-30% triglyceride reduction. 1, 2

Risk Assessment and Treatment Rationale

This patient has moderate hypertriglyceridemia (200-499 mg/dL) and likely elevated LDL-C based on the total cholesterol of 260 mg/dL. 2 At age 34, you must calculate his 10-year ASCVD risk using the pooled cohort equation, but given his young age, his lifetime cardiovascular risk is substantially elevated with these lipid abnormalities. 1

Calculate non-HDL cholesterol (total cholesterol minus HDL-C) with a target goal of <130 mg/dL, as this becomes the secondary treatment target when triglycerides are 200-499 mg/dL. 2

Primary Treatment Algorithm

Step 1: Initiate Statin Therapy

• Start atorvastatin 10-20 mg daily as the preferred option because it provides robust LDL-C reduction (30-40%) and significant triglyceride lowering (15-23% at these doses) in patients with baseline triglycerides >200 mg/dL. 3, 4
• Alternative: Rosuvastatin 5-10 mg daily provides similar efficacy. 1
• Statins are most effective when baseline triglycerides are elevated, with a triglyceride/LDL-C reduction ratio of approximately 0.5 for moderate hypertriglyceridemia. 3

Step 2: Aggressive Lifestyle Modifications (Simultaneous with Medication)

Weight loss is the single most effective intervention: Target 5-10% body weight reduction, which produces a 20% decrease in triglycerides. 2 In some patients, weight loss alone can reduce triglycerides by up to 50-70%. 2

Dietary modifications:

• Restrict added sugars to <6% of total daily calories, as sugar intake directly increases hepatic triglyceride production. 2
• Limit total dietary fat to 30-35% of total calories for moderate hypertriglyceridemia. 2
• Reduce saturated fat to <7% of total energy intake. 2
• Eliminate trans fatty acids completely. 2
• Consume ≥2 servings (8+ ounces) per week of fatty fish rich in omega-3 fatty acids (salmon, trout, sardines). 2
• Increase soluble fiber to >10 g/day. 2

Alcohol restriction: Limit or completely avoid alcohol consumption, as even 1 ounce daily increases triglycerides by 5-10%. 2 Alcohol effects are synergistically exaggerated when coupled with high saturated fat meals. 2

Physical activity: Engage in ≥150 minutes/week of moderate-intensity aerobic activity (or 75 minutes/week vigorous activity), which reduces triglycerides by approximately 11%. 2

Step 3: Screen for Secondary Causes

Before attributing this to primary hyperlipidemia, evaluate for:

• Uncontrolled diabetes mellitus (check HbA1c and fasting glucose) - poor glycemic control is often the primary driver of severe hypertriglyceridemia. 2
• Hypothyroidism (check TSH) - can dramatically elevate both cholesterol and triglycerides. 2
• Excessive alcohol intake - obtain detailed alcohol history. 2
• Medications that raise triglycerides: thiazide diuretics, beta-blockers, estrogen therapy, corticosteroids, antiretrovirals, antipsychotics. 2

Monitoring and Follow-Up Strategy

Recheck fasting lipid panel in 4-8 weeks after initiating statin therapy to assess:

• LDL-C reduction (target ≥30-40% reduction)
• Triglyceride response (goal <200 mg/dL)
• Non-HDL-C (goal <130 mg/dL)
• HDL-C levels 2

Measure baseline ALT/AST and creatinine before starting statin therapy. 5

If Triglycerides Remain >200 mg/dL After 3 Months

If triglycerides remain elevated >200 mg/dL after 3 months of optimized lifestyle modifications and statin therapy, add prescription omega-3 fatty acids (icosapent ethyl 2-4 g daily) as adjunctive therapy. 2 This is specifically indicated if the patient has established cardiovascular disease OR diabetes with ≥2 additional risk factors. 2

Alternative option: Consider fenofibrate 54-160 mg daily if omega-3 criteria are not met, which provides 30-50% triglyceride reduction. 2 However, combination of fibrate with statin increases myopathy risk, so use lower statin doses and monitor creatine kinase levels. 2

Critical Pitfalls to Avoid

Do not delay statin initiation while attempting lifestyle modifications alone - start both simultaneously in this patient with significantly elevated lipids. 5

Do not start with fibrate monotherapy when LDL-C is also elevated - statins address both LDL-C and triglycerides and have proven cardiovascular benefit. 1, 2

Do not use niacin - it showed no cardiovascular benefit when added to statin therapy and increases risk of new-onset diabetes. 2

Do not use over-the-counter fish oil supplements as a substitute for prescription omega-3 fatty acids - they are not equivalent. 2

Monitor for statin-related muscle symptoms and obtain CPK if symptoms develop. 4