What is the best oral medication for a 76-year-old white female with Hyperlipidemia (HLD) and Chronic Kidney Disease (CKD)?

From the Guidelines

For a 76-year-old white female with hyperlipidemia (HLD) and chronic kidney disease (CKD), a moderate-intensity statin such as atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily would be the best oral medication choice. This recommendation is based on the most recent and highest quality study available, which suggests that statins are first-line therapy for hyperlipidemia in patients with CKD as they reduce cardiovascular risk while having minimal renal excretion 1. The patient's advanced age and CKD place her at elevated cardiovascular risk, and statins have demonstrated mortality benefit in this population while maintaining a favorable safety profile when appropriately dosed. Key considerations in the management of this patient include:

• Dose adjustment is important in CKD, particularly for rosuvastatin which should be started at the lower end of the dosing range.
• Regular monitoring of liver function tests and creatine kinase is recommended, especially during the first few months of therapy.
• Patients should be counseled about potential side effects including muscle pain or weakness.
• Ezetimibe 10 mg daily could be added if LDL goals aren't achieved with statin therapy alone. According to the Kidney Disease: Improving Global Outcomes guidelines, patients with CKD who are 50 years and older are considered at sufficiently high risk of a cardiovascular event (10% risk of manifest coronary heart disease over 10 years) to justify statin therapy without the need to apply any formal risk calculation in individual patients 1. The use of lipid-lowering therapy in patients on chronic dialysis is contentious, but this patient is not on dialysis, so statin therapy is recommended. Overall, the benefits of statin therapy in this patient outweigh the risks, and it is recommended as the best oral medication choice for managing her HLD and CKD.

From the FDA Drug Label

Combination with Statins: Ezetimibe Tablet Initiated Concurrently with a Statin In four multicenter, double-blind, placebo-controlled, 12-week trials, in 2,382 patients (age range 18 to 87 years, 57% female; 88% White, 5% Black or African American, 2% Asian, 5% other races mostly identified as Hispanic or Latino) with hyperlipidemia, ezetimibe tablet or placebo was administered alone or with various doses of atorvastatin, simvastatin, pravastatin, or lovastatin. The changes in lipid endpoints after an additional 48 weeks of treatment with ezetimibe tablet coadministered with fenofibrate or with fenofibrate alone were consistent with the 12-week data displayed above

The best oral medication for a 76-year-old white female with hyperlipidemia (HLD) and chronic kidney disease (CKD) is ezetimibe.

• Ezetimibe has been shown to be effective in reducing total-C, LDL-C, Apo B, and non-HDL-C when used alone or in combination with statins.
• The patient's age and race are consistent with the demographics of the patients in the clinical trials.
• Ezetimibe can be used in combination with fenofibrate, which may be beneficial for patients with mixed hyperlipidemia.
• However, it is essential to monitor the patient's kidney function and adjust the dose accordingly, as CKD may affect the drug's pharmacokinetics.
• It is also crucial to consider the potential interactions between ezetimibe and other medications the patient may be taking. 2

From the Research

Treatment Options for Hyperlipidemia in CKD Patients

• The choice of oral medication for a 76-year-old female with hyperlipidemia (HLD) and chronic kidney disease (CKD) depends on various factors, including the stage of CKD and the presence of other comorbidities.
• According to the study 3, dyslipidemias are common in patients with CKD, and lipid-lowering agents have been shown to have potential benefits in slowing CKD progression.
• The study 4 investigated the effects of atorvastatin on renal function in patients with dyslipidemia and CKD, and found that atorvastatin had potential reno-protective effects.

Comparison of Atorvastatin and Rosuvastatin

• The study 5 compared the effects of atorvastatin and conventional lipid-lowering therapy on renal function in patients with dyslipidemia and CKD, and found that atorvastatin did not exhibit significant reno-protective effects.
• However, the study 6 found that atorvastatin increased estimated glomerular filtration rate (eGFR) and decreased serum uric acid levels in CKD patients, whereas rosuvastatin did not have these effects.
• The review 7 compared the properties and clinical outcomes of atorvastatin and rosuvastatin, and suggested that atorvastatin may have advantages over rosuvastatin, especially in treating patients with renal impairment.

Considerations for Treatment

• The choice of oral medication for this patient should be based on individual factors, including the stage of CKD, presence of other comorbidities, and potential side effects of the medication.
• Atorvastatin may be a suitable option for this patient, given its potential reno-protective effects and ability to lower serum uric acid levels, as shown in the studies 4, 6, and 7.