From the FDA Drug Label
Assess LDL-C when clinically appropriate, as early as 4 weeks after initiating atorvastatin calcium, and adjust dosage if necessary Adults: Recommended starting dosage is 10 or 20 mg once daily; dosage range is 10 mg to 80 mg once daily. Patients requiring LDL-C reduction >45% may start at 40 mg once daily.
The patient is already on atorvastatin 40 mg, which is within the recommended dosage range. The LDL-C level is 20 mg/dL, which is below the target level of <100 mg/dL. However, the triglycerides level is high at 486 mg/dL.
- The primary concern is the high triglycerides level, which may require additional treatment.
- The current atorvastatin dosage may not need to be increased, as the LDL-C level is already low.
- Additional treatments, such as fibrates or omega-3 fatty acids, may be considered to address the high triglycerides level 1.
From the Research
I would add fenofibrate to address the patient's dyslipidemia, particularly the significantly elevated triglycerides (310-486 mg/dL) and low HDL (28-31 mg/dL). While the atorvastatin 40mg has effectively lowered LDL to 20 mg/dL, it hasn't adequately addressed the hypertriglyceridemia. Start with fenofibrate 48-145mg daily, with the dose depending on kidney function (lower doses for more severe CKD) 2. This combination therapy is particularly appropriate for diabetic patients with mixed dyslipidemia. Fenofibrate works by activating peroxisome proliferator-activated receptors (PPARs), which increase lipoprotein lipase activity and reduce triglyceride synthesis. Monitor liver function, creatinine, and muscle symptoms when combining with a statin. The patient's elevated triglycerides and low HDL represent residual cardiovascular risk despite good LDL control, and addressing these abnormalities is especially important in a patient with multiple risk factors including diabetes and CKD. Fenofibrate has been shown to decrease triglycerides by 29% and improve flow-mediated dilation, and also reduce non-HDL cholesterol and increase HDL cholesterol 3. Additionally, fenofibrate has been shown to be effective in reducing triglycerides and improving insulin sensitivity in patients with hypertriglyceridemia 4. Overall, the addition of fenofibrate to the patient's current regimen is a reasonable and evidence-based approach to addressing their dyslipidemia and reducing their cardiovascular risk.