How can a 73-year-old woman taking rosuvastatin (Crestor) 10 mg daily with total cholesterol 88 mg/dL, high‑density lipoprotein cholesterol (HDL‑C) 37 mg/dL, triglycerides 103 mg/dL, and low‑density lipoprotein cholesterol (LDL‑C) 32 mg/dL improve her high‑density lipoprotein cholesterol?

Improving HDL Cholesterol in a 73-Year-Old Woman on Rosuvastatin

Primary Recommendation

In this 73-year-old woman with critically low HDL-C (37 mg/dL), the priority is intensive therapeutic lifestyle changes—specifically aerobic exercise, weight optimization, smoking cessation if applicable, and moderate alcohol intake—rather than pharmacologic HDL-raising therapy, because no medication has proven mortality or morbidity benefit for isolated low HDL-C. 1, 2

Critical Context: Reassess the Statin Dose

Your patient's LDL-C of 32 mg/dL on rosuvastatin 10 mg is excessively low and may reflect statin overtreatment. 3, 1

• Consider reducing rosuvastatin to 5 mg daily or switching to a lower-intensity statin, because the current regimen achieves >50% LDL-C reduction (likely from a baseline ~64–80 mg/dL) and may be contributing to the low HDL-C through metabolic effects. 3
• Statins can modestly suppress HDL-C in some patients, particularly at high doses or in those with baseline metabolic syndrome features. 3
• The 2019 ACC/AHA guidelines recommend LDL-C targets of <100 mg/dL for intermediate-risk patients and <70 mg/dL for high-risk patients—not <40 mg/dL. 3
• An LDL-C of 32 mg/dL provides no additional cardiovascular benefit over 50–70 mg/dL and may increase risk of hemorrhagic stroke, cognitive concerns, and metabolic derangements in elderly women. 3

Evidence-Based Lifestyle Interventions to Raise HDL-C

Exercise (Highest Impact)

• Perform ≥30 minutes of moderate-intensity aerobic exercise (brisk walking, cycling, swimming) on most days of the week. 1, 2
• Aerobic exercise raises HDL-C by 5–10% and improves triglycerides by 20–30% within 8–12 weeks. 1
• Resistance training 2–3 days per week provides additional benefit. 1

Weight Management

• Achieve and maintain BMI 18.5–24.9 kg/m² and waist circumference <35 inches. 2
• Every 1 kg of weight loss raises HDL-C by approximately 0.35 mg/dL in overweight individuals. 2

Dietary Modifications

• Limit saturated fat to <7% of total calories (reduce cheese, whole milk, fatty red meat). 1, 2
• Replace saturated fats with monounsaturated fats (olive oil, avocados, nuts) and omega-3 fatty acids (fatty fish 2–3 times weekly). 1
• Avoid trans fats completely. 2
• Consume 10–25 g/day of soluble fiber (oats, beans, vegetables). 1

Alcohol Intake

• Limit alcohol to ≤1 drink per day for women (5 oz wine, 12 oz beer, 1.5 oz spirits). 1
• Moderate alcohol intake raises HDL-C by 5–15%, but excessive intake worsens triglycerides and increases cardiovascular risk. 1

Smoking Cessation

• If the patient smokes, cessation is mandatory—smoking lowers HDL-C by 10–15% and is a major independent cardiovascular risk factor. 2

Why Pharmacologic HDL-Raising Therapy Is Not Recommended

• No medication that raises HDL-C has demonstrated reduction in cardiovascular events, mortality, or quality of life in randomized controlled trials. 1, 2
• Niacin, fibrates, and CETP inhibitors all failed to improve outcomes despite raising HDL-C. 1
• The 2019 ACC/AHA guidelines explicitly state that LDL-C reduction remains the primary therapeutic target; HDL-C and triglycerides should not be prioritized as primary pharmacologic goals. 1
• In elderly women, the risk-benefit ratio of adding HDL-raising drugs (niacin flushing, fibrate myopathy risk, drug interactions) is unfavorable. 3, 1

Monitoring and Follow-Up

• Re-measure a fasting lipid panel 4–6 weeks after reducing rosuvastatin dose. 1
• Target lipid goals for a 73-year-old woman:
  • LDL-C 70–100 mg/dL (depending on cardiovascular risk factors—diabetes, hypertension, prior ASCVD). 3, 1
  • HDL-C >50 mg/dL for women. 1, 4
  • Triglycerides <150 mg/dL. 1, 4
  • Non-HDL-C <130 mg/dL (or <100 mg/dL if high risk). 1
• Once lipid goals are stable, perform annual lipid testing. 1, 2
• Assess muscle symptoms at each visit; obtain creatine kinase only if symptoms develop. 1

Clinical Pearls and Pitfalls

• Do not add fibrates or niacin to raise HDL-C in this patient—the combination with rosuvastatin increases myopathy risk (especially gemfibrozil, which is contraindicated with statins), and no outcome benefit exists. 3, 1
• Low HDL-C in the setting of very low LDL-C and normal triglycerides may reflect genetic factors (CETP deficiency variants) or metabolic effects of aggressive statin therapy rather than modifiable cardiovascular risk. 1, 4
• In elderly women, statin-associated diabetes risk is modestly increased (HR 1.49 in JUPITER trial for women on rosuvastatin), particularly in those with impaired fasting glucose or metabolic syndrome. 3
• The patient's total cholesterol of 88 mg/dL is in the lowest 1st percentile for her age—this extreme lipid profile warrants reassessment of statin necessity, baseline lipid levels, and cardiovascular risk factors. 3, 4
• If the patient has established ASCVD (prior MI, stroke, PAD), continue rosuvastatin 10 mg and target LDL-C 55–70 mg/dL; if she is primary prevention, reduce the dose. 3

Algorithm for Decision-Making

1. Determine cardiovascular risk category:

   • Established ASCVD (prior MI, stroke, PAD, revascularization) → high risk. 3
   • Diabetes + age >65 → high risk. 3
   • ≥2 risk factors (hypertension, smoking, family history) + 10-year ASCVD risk ≥7.5% → intermediate risk. 3
   • <2 risk factors + 10-year ASCVD risk <7.5% → low risk. 2

2. Adjust rosuvastatin dose based on risk:

   • High risk: Continue rosuvastatin 10 mg; target LDL-C 55–70 mg/dL. 3
   • Intermediate risk: Reduce to rosuvastatin 5 mg; target LDL-C 70–100 mg/dL. 3, 2
   • Low risk: Consider discontinuing statin or switching to rosuvastatin 5 mg; target LDL-C <100 mg/dL. 2

3. Initiate intensive lifestyle changes for HDL-C:

   • Aerobic exercise ≥30 min/day, 5 days/week. 1, 2
   • Weight loss if BMI >25 kg/m². 2
   • Dietary fat modification (↓saturated fat, ↑monounsaturated fat, omega-3). 1, 2
   • Moderate alcohol (≤1 drink/day). 1
   • Smoking cessation if applicable. 2

4. Re-check lipids in 4–6 weeks:

   • If HDL-C improves to >40 mg/dL and LDL-C remains at goal, continue current regimen. 1
   • If HDL-C remains <40 mg/dL despite lifestyle changes, accept this as the patient's baseline and focus on optimizing other cardiovascular risk factors (blood pressure, glucose, aspirin if indicated). 1, 2

5. Do not add pharmacologic HDL-raising therapy (fibrates, niacin, CETP inhibitors)—no mortality or morbidity benefit. 1