In a 66‑year‑old woman taking rosuvastatin 5 mg daily, with total cholesterol 139 mg/dL, LDL‑cholesterol 64 mg/dL, HDL‑cholesterol 48 mg/dL, and triglycerides 208 mg/dL, is any change in therapy needed?

Management of Elevated Triglycerides in a 66-Year-Old Woman on Rosuvastatin 5 mg

Add ezetimibe 10 mg daily to the current rosuvastatin 5 mg regimen to address the elevated triglycerides (208 mg/dL) and optimize LDL-C control, while simultaneously implementing intensive lifestyle modifications targeting triglyceride reduction.

Current Lipid Assessment

• Triglycerides of 208 mg/dL exceed the normal threshold (<150 mg/dL) and require therapeutic intervention. 1
• LDL-C of 64 mg/dL is well below the target of <100 mg/dL for primary prevention and <70 mg/dL for high-risk patients. 1
• HDL-C of 48 mg/dL falls just below the protective threshold of ≥50 mg/dL for women, representing a modifiable risk factor. 2
• Total cholesterol of 139 mg/dL is in the desirable range (<200 mg/dL). 2
• Non-HDL-C can be calculated as 139 - 48 = 91 mg/dL, which is excellent (<130 mg/dL target). 2

Risk Stratification for a 66-Year-Old Woman

• At age 66, this patient falls into the "elderly" category (66-75 years) where ACC/AHA, CCS, and USPSTF guidelines provide Class I risk-based recommendations for statin therapy continuation. 1
• The primary concern is not LDL-C (already at goal) but rather the elevated triglycerides and borderline-low HDL-C, both of which increase residual cardiovascular risk despite statin therapy. 2

Pharmacologic Recommendation: Add Ezetimibe

• Adding ezetimibe 10 mg daily to rosuvastatin 5 mg is recommended because combination therapy provides superior lipid profile improvement compared to statin dose uptitration. 3
• The European Society of Cardiology and American College of Cardiology both recommend adding ezetimibe rather than increasing the statin dose when additional LDL-C lowering is needed or when optimizing the overall lipid profile. 3
• Ezetimibe provides an additional 15-25% LDL-C reduction and has favorable effects on triglycerides and non-HDL-C. 3, 4
• The I-ROSETTE trial demonstrated that rosuvastatin + ezetimibe combinations achieve >50% LDL-C reduction from baseline with a safety profile comparable to statin monotherapy. 3
• Fixed-dose combinations improve adherence by reducing pill burden. 3

Intensive Lifestyle Modifications for Triglyceride Reduction

Dietary Interventions (Primary Focus)

• Reduce simple carbohydrate intake (sweets, sugar-sweetened beverages, refined grains, white bread, pastries) to lower triglycerides by 20-50%. 2
• Limit saturated fat to <7% of total daily calories by eliminating cheese, whole milk, fatty red meat, butter, and tropical oils. 2
• Restrict dietary cholesterol to <200 mg per day. 2
• Increase omega-3 fatty acid intake by consuming fatty fish (salmon, mackerel, sardines) at least twice weekly; for persistent triglycerides >200 mg/dL, consider 1-4 g/day of fish oil supplements under physician supervision. 2
• Consume 10-25 g/day of soluble fiber from oats, beans, lentils, vegetables, and whole grains. 2

Alcohol Restriction

• Limit alcohol to ≤1 drink per day for women, as excess intake elevates triglycerides. 2

Physical Activity

• Perform moderate-intensity aerobic exercise (brisk walking, jogging, cycling) for ≥30 minutes on most days of the week to favorably modify HDL-C and triglycerides. 2, 4
• Aim for ≥150 minutes per week of moderate-intensity activity distributed throughout the week. 2

Weight Management

• If BMI ≥25 kg/m², target a 10% body-weight reduction within the first year through caloric restriction and increased activity; each kilogram lost raises HDL-C by ~0.4 mg/dL. 2
• Maintain BMI between 18.5-24.9 kg/m² and waist circumference <35 inches for women. 4

Monitoring Protocol After Adding Ezetimibe

• No additional baseline labs are required before adding ezetimibe if recent hepatic transaminases (ALT/AST) are normal. 4
• Re-measure a fasting lipid panel 4-6 weeks after initiating ezetimibe to assess response. 3, 4
• Target goals: triglycerides <150 mg/dL, HDL-C >50 mg/dL for women, non-HDL-C <130 mg/dL, and maintain LDL-C <100 mg/dL. 4
• Measure ALT/AST at 8-12 weeks after ezetimibe initiation; routine hepatic monitoring thereafter is unnecessary unless clinically indicated. 4
• Assess for muscle symptoms at each visit; obtain creatine kinase (CK) only if symptoms develop. 4
• Once lipid goals are achieved and stable, perform annual fasting lipid assessments. 2, 4

Alternative Consideration: Fenofibrate (If Triglycerides Remain Elevated)

• If triglycerides remain ≥200 mg/dL after 8-12 weeks of ezetimibe + lifestyle modifications, consider adding fenofibrate 160 mg daily. 5
• Fenofibrate primarily lowers VLDL triglycerides and VLDL cholesterol; in patients with baseline triglycerides 200-500 mg/dL, fenofibrate reduces triglycerides by approximately 35-46%. 5
• However, fenofibrate can increase LDL-C in some patients with hypertriglyceridemia, requiring close monitoring. 5
• The combination of statin + fenofibrate carries an increased risk of myopathy; monitor CK and muscle symptoms closely. 5

Rationale for Not Increasing Rosuvastatin Dose

• Rosuvastatin 5 mg already produces 42-52% LDL-C reduction, and the patient's LDL-C of 64 mg/dL is well below target. 6, 7
• Doubling rosuvastatin from 5 mg to 10 mg yields only an additional 6-7% LDL-C reduction, which is unnecessary given the current LDL-C level. 3
• Increasing the statin dose does not effectively address the primary problem of elevated triglycerides and borderline-low HDL-C. 3
• Higher statin doses increase the risk of dose-dependent adverse effects (myalgia, liver enzyme elevations) without addressing the residual triglyceride-mediated risk. 3

Critical Pitfalls to Avoid

• Do not ignore elevated triglycerides (>200 mg/dL) simply because LDL-C is at goal; elevated triglycerides independently increase cardiovascular risk and require intervention. 2
• Do not increase the rosuvastatin dose when the LDL-C is already at target; this exposes the patient to unnecessary side effects without addressing the actual lipid abnormality. 3
• Do not underestimate the impact of comprehensive dietary modification on triglycerides; reducing simple carbohydrates and increasing omega-3 fatty acids can lower triglycerides by 20-50%. 2
• Do not start fenofibrate before attempting ezetimibe + intensive lifestyle changes, as the statin-fibrate combination carries higher myopathy risk. 5
• Do not overlook the borderline-low HDL-C (48 mg/dL); lifestyle interventions (exercise, weight loss, moderate alcohol if appropriate) can raise HDL-C by 5-15%. 2