Omega-3 Fatty Acids (Salmon Oil) Dosing with Statin and Ezetimibe Therapy
For patients already on statin and ezetimibe therapy, omega-3 fatty acids from fish oil (including salmon oil) should be dosed at 1 gram per day of combined EPA and DHA for cardiovascular risk reduction, or 3-4 grams per day if triglycerides remain elevated above 150 mg/dL. 1, 2
Standard Cardiovascular Protection Dosing
Patients with established cardiovascular disease should consume approximately 1 gram per day of combined EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) from fish oil supplements when already on statin therapy 2
For primary prevention in patients without established cardiovascular disease but on lipid-lowering therapy, at least 500 mg per day of combined EPA and DHA is recommended 2
The American Diabetes Association recommends increasing dietary omega-3 fatty acids from fish as part of lifestyle modification for patients with diabetes on statin therapy 1
Hypertriglyceridemia Management
If triglycerides remain ≥150 mg/dL (1.7 mmol/L) despite statin and ezetimibe therapy, increase omega-3 dosing to 3-4 grams per day of combined EPA and DHA 1, 2
This higher dose reduces triglycerides by 20-50% and is specifically indicated for persistent hypertriglyceridemia 2
The American Heart Association recommends considering omega-3 fatty acids (1 g/day) for additional cardiovascular risk reduction in patients already on lipid-lowering therapy 3
Evidence for Combination Therapy
Combination therapy with omega-3 fatty acids and statins is safe and effective, improving lipid profiles beyond statin monotherapy 2, 4
When omega-3 fatty acids (900-1,800 mg/day EPA) were added to patients already on statins, total cholesterol decreased significantly (from 5.63 to 5.02 mmol/L), triglycerides dropped dramatically (from 2.07 to 1.08 mmol/L), and HDL-cholesterol increased (from 1.23 to 1.34 mmol/L) 5
The combination does not increase risk for adverse muscle or liver effects and requires no additional laboratory monitoring beyond standard statin monitoring 4
Practical Implementation
Two servings of oily fish per week provides only 400-500 mg/day of EPA and DHA, which is insufficient for secondary prevention or hypertriglyceridemia 2
Patients requiring 1 gram per day or higher doses must use fish oil supplements (including salmon oil) to achieve therapeutic targets 2
Salmon oil supplements should contain both EPA and DHA; verify the combined EPA+DHA content on the label, not just total fish oil content 2
Critical Caveat About Primary Lipid Management
Omega-3 fatty acids are adjunctive therapy only and do not replace the need to optimize statin and ezetimibe dosing first. The guidelines prioritize:
- Maximally tolerated statin therapy (high-intensity when indicated) 1
- Addition of ezetimibe when LDL-C remains ≥70 mg/dL in very high-risk patients 1, 6
- PCSK9 inhibitors if LDL-C remains ≥70 mg/dL despite maximal statin plus ezetimibe 1
Omega-3 fatty acids provide complementary benefits for triglyceride reduction and cardiovascular protection but are not included in the evidence-based treatment algorithm for LDL-C reduction 7
If LDL-C goals are not met on current statin and ezetimibe therapy, intensify statin therapy (switch to high-intensity statin if not already on one) or add a PCSK9 inhibitor rather than relying on omega-3 supplementation alone 7, 6