How to manage hypercholesterolemia and hypertriglyceridemia in a patient?

Management of Hypercholesterolemia and Hypertriglyceridemia

Initial Assessment

This 53-year-old woman with total cholesterol 249 mg/dL and triglycerides 150 mg/dL has mild hypertriglyceridemia and borderline high cholesterol that requires aggressive lifestyle modification as first-line therapy, with statin consideration based on her 10-year ASCVD risk calculation. 1

Before initiating any pharmacotherapy, you must evaluate for secondary causes including:

• Uncontrolled diabetes or prediabetes (check HbA1c and fasting glucose) 1, 2
• Hypothyroidism (check TSH) 1, 2
• Excessive alcohol intake (detailed quantitative history) 3, 1
• Medications that raise lipids (thiazide diuretics, beta-blockers, estrogen therapy, corticosteroids) 1
• Renal disease (check creatinine and urinalysis) 1

Calculate her 10-year ASCVD risk using the pooled cohort equations to determine if statin therapy is indicated. 2

Lifestyle Modifications (Mandatory First-Line Therapy)

Weight Management

• Target 5-10% body weight reduction, which produces a 20% decrease in triglycerides and can reduce levels by up to 50-70% in some patients. 1, 2
• Weight loss of 1 kg reduces triglycerides by approximately 1.5-1.9 mg/dL. 1

Dietary Interventions

• Restrict added sugars to <6% of total daily calories and eliminate all sugar-sweetened beverages completely, as sugar intake directly increases hepatic triglyceride production. 3, 1, 2
• Limit total fat to 30-35% of total daily calories for mild-moderate hypertriglyceridemia. 3, 1, 2
• Restrict saturated fats to <7% of total calories, replacing with polyunsaturated or monounsaturated fats. 1
• Eliminate trans fatty acids completely. 1
• Increase soluble fiber to >10 g/day from sources like oats, beans, and vegetables. 3, 1
• Consume ≥2 servings (8+ ounces) per week of fatty fish (salmon, trout, sardines, anchovies) rich in EPA and DHA. 1
• Replace refined carbohydrates with fiber-rich whole grains, as low-carbohydrate diets are more effective than low-fat diets for reducing triglycerides. 1, 4

Alcohol Restriction

• Limit alcohol to no more than 1 standard drink per day (12 oz beer, 5 oz wine, or 1.5 oz spirits), as even 1 ounce daily increases triglycerides by 5-10%. 3, 1, 2
• Alcohol effects are synergistically exaggerated when coupled with meals high in saturated fat. 3

Physical Activity

• Engage in at least 150 minutes per week of moderate-intensity aerobic activity (or 75 minutes per week of vigorous activity), which reduces triglycerides by approximately 11%. 3, 1, 2
• Regular aerobic training is superior to resistance training for triglyceride reduction (11% vs 6% reduction). 3

Pharmacologic Therapy Algorithm

If 10-Year ASCVD Risk ≥7.5%

Initiate moderate-intensity statin therapy (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily) as the primary pharmacologic intervention, which provides 10-30% dose-dependent triglyceride reduction and proven cardiovascular risk reduction. 1, 2

If 10-Year ASCVD Risk 5% to <7.5%

Engage in patient-clinician discussion regarding statin initiation, as persistently elevated triglycerides ≥150 mg/dL constitute a cardiovascular risk-enhancing factor that may favor treatment. 1, 2

If 10-Year ASCVD Risk <5%

Focus exclusively on intensive lifestyle modifications for 3-6 months before considering pharmacotherapy. 1, 2

Monitoring and Follow-Up

• Reassess fasting lipid panel in 6-12 weeks after implementing lifestyle modifications. 1, 2
• If statin therapy is initiated, recheck lipids 4-8 weeks after starting or adjusting medication. 1
• Calculate non-HDL cholesterol (total cholesterol minus HDL cholesterol) with a target goal of <130 mg/dL if triglycerides remain 150-199 mg/dL. 1, 2

Critical Pitfalls to Avoid

• Do not initiate pharmacotherapy without first addressing secondary causes, particularly uncontrolled diabetes or hypothyroidism, as treating these conditions can dramatically reduce lipid levels independent of lipid medications. 1, 5
• Do not use bile acid sequestrants if triglycerides are >200 mg/dL, as they are relatively contraindicated and can worsen hypertriglyceridemia. 1
• Do not substitute over-the-counter fish oil supplements for prescription omega-3 formulations if pharmacotherapy becomes necessary, as they are not equivalent. 1

When to Intensify Therapy

If after 3 months of optimized lifestyle modifications and statin therapy (if indicated), triglycerides remain >200 mg/dL, consider adding prescription omega-3 fatty acids (icosapent ethyl 2-4 g/day), particularly if the patient has established cardiovascular disease or diabetes with ≥2 additional risk factors. 1, 2