This article originally posted 24 March, 2012 and appeared in Issue 439
Test Your Knowledge Answer #439
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Answer and Critique (Correct Answer = Increase atorvastatin to 20 mg daily)
Key Points:
The statin dosage should be titrated up to achieve LDL and non–HDL cholesterol goals.
On his current treatment, this patient has an LDL cholesterol level of less than 100 mg/dL (2.59 mmol/L), an elevated triglyceride level, and a low level of HDL cholesterol in the absence of cardiovascular disease. According to the current update of the National Cholesterol Education Program guidelines, the statin therapy should be intensive enough to achieve an LDL cholesterol reduction of 30% to 40% from baseline value. In addition, a non–HDL cholesterol goal of less than 130 mg/dL (3.36 mmol/L) should be pursued in patients with a triglyceride level that is greater than 200 mg/dL (2.26 mmol/L). This patient's HDL cholesterol is 147 mg/dL (3.8 mmol/L), which is another indication to increase the statin dosage.
Adding ezetimibe is a possible alternative if the higher statin dosage is not tolerated, although this occurrence is relatively rare. The addition of fenofibrate or niacin will help lower the triglyceride level and raise HDL cholesterol levels; however, no long-term clinical trials have yet established the safety and efficacy of these agents in preventing cardiovascular disease.
Bibliography
American Diabetes Association. Standards of medical care in diabetes—2006 [published erratum appears in Diabetes Care 2006;29:1192]. Diabetes Care. 2006;29 Suppl 1:S4-42. [PMID: 16373931] [PubMed]
National Heart, Lung, and Blood Institute. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227-39. [PMID: 15249516] [PubMed]
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