From the Guidelines
The patient's current LDL level of 106 mg/dL is above the target of <100 mg/dL, and I recommend adding ezetimibe 10 mg daily to the existing atorvastatin regimen to further lower LDL levels and reduce cardiovascular risk. The patient's cholesterol profile shows improvement over the past three years, with total cholesterol decreasing from 253 mg/dL to 210 mg/dL, but the LDL remains elevated. The patient has excellent HDL levels (90 mg/dL) and normal triglycerides (71 mg/dL), which are protective factors. The calculated VLDL is also within normal range at 14.2 mg/dL. According to the 2019 guidelines for the management of blood cholesterol 1, adding ezetimibe to a statin can provide an additional 15-20% LDL reduction, which can help achieve the target LDL level. The IMPROVE-IT study 1 demonstrated that the addition of ezetimibe to simvastatin reduced the risk of major adverse cardiovascular events. Lifestyle modifications should continue, including a heart-healthy diet low in saturated fats, regular physical activity, and weight management. The patient should be monitored with repeat lipid testing in 3 months after any medication changes to assess efficacy and tolerability.
Some key points to consider in this patient's management include:
- The importance of achieving an LDL level below 100 mg/dL for cardiovascular risk reduction, as recommended by the 2019 guidelines for the management of blood cholesterol 1
- The potential benefits of adding ezetimibe to the existing atorvastatin regimen, as demonstrated by the IMPROVE-IT study 1
- The need for ongoing lifestyle modifications, including a heart-healthy diet and regular physical activity, to support cardiovascular health
- The importance of monitoring the patient's lipid profile and adjusting the treatment plan as needed to achieve optimal cardiovascular risk reduction.
The 2007 guidelines for cardiovascular disease prevention in women 2 also emphasize the importance of lifestyle modifications, including a heart-healthy diet and regular physical activity, for reducing cardiovascular risk. However, the more recent 2019 guidelines for the management of blood cholesterol 1 provide more specific recommendations for the use of ezetimibe in combination with statins for LDL lowering.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient's Current Condition
The patient is a 66-year-old female with hypertension (HTN) and is currently on benicar and atorvastatin. Her recent lab results for cholesterol levels are as follows:
- Cholesterol: 210 mg/dL (high)
- Triglycerides: 71 mg/dL
- HDL: 90 mg/dL
- LDL: 106 mg/dL (high)
- VLDL: 14.2 mg/dL
Relevant Studies
- According to 3, statins may not be sufficient in decreasing LDL cholesterol levels, and the addition of ezetimibe or PCSK9 inhibitors can provide additional LDL cholesterol reduction and decrease ASCVD risk.
- A study on atorvastatin 4 found that it reduces levels of total cholesterol, LDL-cholesterol, triglyceride, and VLDL-cholesterol, and increases HDL-cholesterol in patients with dyslipidaemias.
- The use of rosuvastatin-based combination treatment with ezetimibe or acetylsalicylic acid 5 is recommended for patients at high and very high cardiovascular risk.
- A quantitative approach to determining when to add nonstatin therapy 6 suggests that adding ezetimibe or PCSK9 monoclonal antibodies to maximally tolerated statin therapy may be cost-effective in very high-risk and high-risk patients, depending on baseline LDL-C levels.
- A study on ezetimibe added to statin therapy after acute coronary syndromes 7 found that the combination of simvastatin and ezetimibe resulted in incremental lowering of LDL cholesterol levels and improved cardiovascular outcomes.
Potential Treatment Options
- Consider adding ezetimibe to the patient's current statin therapy to further reduce LDL cholesterol levels and decrease ASCVD risk, as suggested by 3 and 7.
- Monitor the patient's response to the current atorvastatin therapy and consider adjusting the dosage or adding other lipid-lowering agents if necessary, based on the findings of 4 and 6.
- Evaluate the patient's cardiovascular risk and consider using a rosuvastatin-based combination treatment with ezetimibe or acetylsalicylic acid, as recommended by 5.
Key Considerations
- The patient's LDL cholesterol level is currently high, and reducing it to below 100 mg/dL may provide additional benefit, as suggested by 7.
- The use of nonstatin therapies, such as ezetimibe or PCSK9 inhibitors, may be necessary to achieve optimal LDL cholesterol levels and reduce ASCVD risk, as discussed in 3 and 6.