What are the treatment options for a patient with elevated cholesterol and triglycerides?

Treatment Recommendation for Elevated Cholesterol and Triglycerides

Start this 63-year-old male on moderate-intensity statin therapy immediately (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily), combined with lifestyle modifications, to target an LDL-C reduction of at least 30% with a goal of <100 mg/dL. 1

Risk Stratification and Treatment Rationale

This patient's lipid profile shows:

• Total cholesterol: 209 mg/dL (borderline high)
• LDL-C: 131 mg/dL (above optimal)
• Triglycerides: 213 mg/dL (moderate hypertriglyceridemia, defined as 175-499 mg/dL) 1

For patients aged 40-75 years without established atherosclerotic cardiovascular disease (ASCVD) or diabetes, the 2018 ACC/AHA guidelines recommend calculating 10-year ASCVD risk to determine statin intensity. 1 However, the presence of persistent hypertriglyceridemia (≥175 mg/dL) is a risk-enhancing factor that supports initiating at least moderate-intensity statin therapy even if the calculated 10-year risk is 5-7.5%. 1

First-Line Pharmacological Treatment

Moderate-intensity statin options include: 1, 2

• Atorvastatin 10-20 mg daily (achieves 30-40% LDL-C reduction)
• Rosuvastatin 5-10 mg daily (achieves 30-40% LDL-C reduction)
• Simvastatin 20-40 mg daily (achieves 30-40% LDL-C reduction)

Statins provide dual benefit in this patient: they lower LDL-C by 30-40% and simultaneously reduce triglycerides by 10-30% in a dose-dependent manner. 1, 3 This addresses both lipid abnormalities with a single agent.

Concurrent Lifestyle Modifications

Implement these specific dietary changes immediately: 1

• Reduce saturated fat to <7% of total calories
• Limit dietary cholesterol to <200 mg/day
• Reduce refined carbohydrates and added sugars (particularly important for triglyceride management) 1
• Avoid or minimize alcohol consumption (triglyceride-raising) 1
• Increase physical activity to at least 150 minutes/week of moderate-intensity exercise 1

For additional LDL-C lowering, add: 2

• Plant stanols/sterols: 2 g/day (provides 5-10% additional LDL-C reduction)
• Viscous fiber: 10-25 g/day (provides additional 5-10% LDL-C reduction)

Monitoring Protocol

Initial monitoring schedule: 1, 2

• Measure lipid panel 4-12 weeks after initiating statin therapy to assess response
• Check baseline ALT/AST and creatinine before starting statin 2
• Assess for muscle-related symptoms at each visit 1

Target goals: 1, 2

• Primary goal: LDL-C <100 mg/dL (or at least 30-40% reduction from baseline)
• Secondary goal: Triglycerides <150 mg/dL

If Initial Therapy Is Insufficient

If LDL-C remains >100 mg/dL after 3 months on maximally tolerated statin: 1, 2

1. Add ezetimibe 10 mg daily (provides additional 15-20% LDL-C reduction) - this is the preferred first add-on agent
2. Consider intensifying statin to high-intensity if tolerated

If triglycerides remain ≥200 mg/dL despite statin therapy and lifestyle changes: 1

1. Prescription omega-3 fatty acids (icosapent ethyl 2-4 g daily or omega-3 acid ethyl esters) can be added
2. Fenofibrate may be considered if triglycerides remain persistently elevated, though combination with statins increases myositis risk 1, 4

Critical Pitfalls to Avoid

Do not use niacin in combination with statins - the AIM-HIGH trial demonstrated no benefit on cardiovascular outcomes and a possible increase in ischemic stroke risk. 1

Monitor for statin-related side effects: 1

• Muscle pain or weakness (myopathy risk)
• Liver enzyme elevations (check if symptoms develop)
• New-onset diabetes risk is minimal (1.5% vs 1.2% on placebo over 5 years) but cardiovascular benefits far outweigh this risk 1

If combining fibrate with statin for severe hypertriglyceridemia: 1

• Fenofibrate is preferred over gemfibrozil (lower myositis risk)
• Monitor closely for muscle symptoms
• This combination is generally reserved for triglycerides >500 mg/dL to prevent pancreatitis

Address secondary causes of hypertriglyceridemia: 1

• Screen for diabetes/prediabetes (HbA1c)
• Check thyroid function (TSH)
• Review medications that raise triglycerides (beta-blockers, thiazides, oral estrogens, atypical antipsychotics)

Why Not More Aggressive Initial Therapy?

Without knowing this patient's 10-year ASCVD risk score or presence of diabetes/established ASCVD, moderate-intensity statin is the appropriate starting point. 1 If he has diabetes, established ASCVD, or calculated 10-year risk ≥7.5%, then high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) should be initiated instead. 1, 2

The patient's 20-pound weight loss demonstrates motivation for lifestyle changes, which should be strongly reinforced as these modifications can achieve up to 25-30% LDL-C reduction when combined with statin therapy. 1