BM is a 58-year-old African American male with a history of type 2 diabetes, chronic kidney disease, and hypertension who returns to clinic for follow up on lipid management.
The patient states he has been adherent to maximal lifestyle modifications and pharmacotherapy.
He walks his dog 30 minutes a day for 5 days a week.
Past Medical History
Type 2 Diabetes
Chronic Kidney Disease (55 mL/min)
Hypertension
Patient does not have any known history of atherosclerotic cardiovascular disease (ASCVD).
Social History
Tobacco - smokes 14 cigarettes per day for 15 years; not willing to quit.
denies alcohol use
Current Medications
Metformin 500 mg PO twice daily
Aspirin 81 mg PO daily
Lisinopril 2.5 mg PO daily
Rosuvastatin 40 mg PO daily
Vitals
Ht 5'10'' Wt 230 lbs. BMI 33 kg/m2 BP 128/80 mmHg HR 76 bpm RR 14
Other parts of the physical exam were unremarkable.
Labs (3 months ago)
Fasting lipid panel: TC 206 mg/dL, HDL-C 40 mg/dL, LDL-C 132 mg/dL, triglycerides 170 mg/dL
A1c: 6.5%
Other labs and physical exam were within normal limits
10-year ASCVD risk was estimated to be 37.2% by the Pooled Cohort Equation.
Rosuvastatin 40 mg PO daily was prescribed 3 months ago.
Today's Fasting Lipid Panel
Total Cholesterol: 180 mg/dL
HDL-C: 40 mg/dL
LDL-C: 90 mg/dL
Triglycerides: 150 mg/dL
The correct answer is: B. Continue rosuvastatin 40 mg PO daily. Add ezetimibe 10 mg PO daily.
Option B is the correct choice. According to the 2018 cholesterol guideline, in adults 40 to 75 years of age with diabetes mellitus and an LDL-C of 70 to 189 mg/dL, it is reasonable to assess the 10-year ASCVD risk using the Pooled Cohort Equation.1 This patient's estimated 10-year ASCVD risk was 37.2% based on the Pooled Cohort Equations. Since his 10-year ASCVD risk is ≥20%, he is at high risk for ASCVD event.1 High-intensity statin therapy was initiated 3 months ago with the goal to reduce his LDL-C by at least 50% for the primary prevention of ASCVD. The patient states he is adherent to the high-intensity statin therapy. However, he has not achieved a 50% LDL-C reduction. According to the 2018 cholesterol guideline, in adults with diabetes mellitus with a 10-year ASCVD risk of 20% or higher it may be reasonable to add ezetimibe to maximally tolerated statin therapy to further reduce LDL-C by 50% or more.1
Option A is incorrect because the patient is already taking a high-intensity statin and changing to a different high-intensity statin will not likely provide additional LDL-C lowering. Rosuvastatin 40 and atorvastatin 80 mg are likely to achieve similar LDL-C reduction.1
Option C is incorrect. There is no randomized controlled trial data showing the benefit of PCSK9 inhibitors in primary prevention. According to the 2018 cholesterol guideline, a PCSK9 inhibitor may be considered in secondary prevention patients, especially those who are at very high-risk for ASCVD and whose LDL-C remains ≥70 mg/dL on maximally tolerated statin and ezetimibe therapy; in patients 30-75 years of age with heterozygous FH with an LDL-C level of ≥100 mg/dL while taking maximally tolerated statin and ezetimibe therapy; or in patients 40-75 years of age with a baseline LDL-C level ≥ 220 mg/dL and who achieve an on-treatment LDL-C level of ≥130 mg/dL while on a maximally tolerated statin and ezetimibe therapy.1
Option D is incorrect because according to the 2018 cholesterol guideline, in adults with diabetes mellitus and with a 10-year ASCVD risk of 20% or higher it is reasonable to add ezetimibe to a maximally tolerated statin to reduce LDL-C by 50% or more.1 The patient did not achieve at least 50% LDL-C reduction with high-intensity statin therapy. Therefore, adding ezetimibe would provide additional LDL-C reduction and improve cardiovascular outcomes.
References
- Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;73:3168-3209.
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