A Middle-Aged Man With CAD, Hyperlipidemia, and Statin Intolerance

A 60-year-old Caucasian man is referred for management of elevated cholesterol. He has history of obesity, hypertension, and hyperlipidemia. He had a non–ST-segment elevation myocardial infarction (NSTEMI) one year ago with drug-eluting stent placement in his right coronary artery. His current medications include aspirin 81 mg daily, lisinopril 20 mg daily, and metoprolol XL 50 mg daily. His physical exam is notable for a body mass index (BMI) of 32 kg/m2 but is otherwise unremarkable. His blood pressure is 135/85 mm Hg.

A recent lipid panel shows the following:

  • Total Cholesterol: 226 mg/dL
  • Triglycerides: 154 mg/dL
  • High-Density Lipoprotein Cholesterol (HDL-C): 39 mg/dL
  • Friedewald-Estimated Low-Density Lipoprotein Cholesterol (LDL-C): 156 mg/dL
  • He has a normal creatinine and normal liver enzymes. His TSH and vitamin D levels are within normal limits.

He was advised to lose weight and referred to a weight loss counselor. He also started rosuvastatin 20 mg daily but developed severe aching in his thighs and calves muscles. He discontinued the medication with resolution of his aches. Then, he started atorvastatin 20 mg daily but again developed aching in his thighs. Similar aches occurred on a red yeast rice/CoQ10 combination and intermittent dosing of simvastatin 20 mg weekly and rosuvastatin 5 mg weekly. His creatine kinase levels were never elevated during his episodes of muscle aches. He is not willing to try any more statin therapy.

Which of the following approved non-statin lipid-lowering agents has randomized clinical trial evidence for cardiovascular event reduction as monotherapy in this patient?

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