Approach to Statin Intolerance Within the Risk Reduction Toolbox
A 60-year-old female patient presents to the clinic for follow up. She has a history of hypertension, hyperlipidemia, and prior angina. Past work-up revealed the presence of coronary artery disease (CAD) diagnosed by CT coronary angiography, which showed a calcium score of 213 and CAD-RADS 3 disease (stenosis 50-69%) in the proximal left circumflex. She is being treated with medical therapy for her stable CAD and is currently free of symptoms. She also has a family history of premature CAD in her father. Her current medications include aspirin 81mg, pravastatin 20mg, ezetimibe 10mg, and amlodipine 2.5mg daily. Her lipid panel on current treatment shows total cholesterol 181 mg/dL, LDL-C 103 mg/dL, HDL-C 61 mg/dL, and triglycerides 85 mg/dL. Lp(a) is <8.4 nmol/L and high-sensitivity CRP (hsCRP) is 0.8 mg/L. She is a marathon runner and was previously unable to tolerate atorvastatin, rosuvastatin, or a higher dose of pravastatin due to muscle pain after running.
What is the next best step in her lipid management?