Ms. Jones is a 62-year-old Hispanic female who has a past medical history of diabetes and hypertension. Her LDL-C was 174 mg/dL prior to initiating statin therapy. Her 10-year ASCVD risk was >7.5% using the pooled cohort equations. She is on appropriate guideline-directed medical therapy for hypertension, and her blood pressure is at goal.
Ms. Jones returned to clinic today. She states adherence with optimal lifestyle modifications and atorvastatin 20 mg PO daily. Her fasting LDL-C is now 108 mg/dL (decreased 38% from baseline). Her non-HDL-C is 173 mg/dL, and her triglycerides are 324 mg/dL. She is willing to take additional therapy to lower her ASCVD risk.
According to the 2016 ACC Expert Consensus Decision Pathway (ECDP) on non-statin therapies, which of the following recommendations should be considered for this patient?
The correct answer is: B. Increase atorvastatin dose to achieve >50% LDL-C reduction.
The patient has diabetes and a 10-year ASCVD risk >7.5%. The patient states adherence to moderate-intensity statin therapy and lifestyle modifications, and she achieved the expected >30% to <50% LDL-C reduction from baseline while on this therapeutic regimen. Her on-treatment LDL-C is 108 mg/dL and non-HDL-C is 173 mg/dL.
The 2016 ACC ECDP uses thresholds to guide the decision making for intensifying lipid lowering therapy. For a patient with diabetes who is between 40-75 years of age with an estimated 10-year ASCVD risk >7.5%, the clinician should determine if the patient has achieved the threshold of >50% LDL-C reduction from baseline or the optional thresholds of LDL-C <100 mg/dL or non-HDL-C <130 mg/dL while on maximally tolerated statin therapy. According to the ECDP, if these thresholds are not achieved in adherent patients, the clinician may consider intensifying therapy.
The clinician and patient should discuss the potential net ASCVD benefit before intensifying medication therapy. The discussion should include the risk of adverse effects, potential drug-drug interactions, and patient preferences. Using the 2016 ACC ECDP algorithm, the patient should receive high-intensity statin (atorvastatin 40, 80 mg; rosuvastatin 20, 40 mg) before a non-statin is added to her regimen. The ECDP aligns with the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Risk in Adults, which states that high-intensity statin therapy is reasonable for patients with diabetes, who are between 40-75 years of age, with an estimated 10-year ASCVD risk >7.5%.
Options A, C, and D are not the best options for this patient. The patient is taking a moderate-intensity statin dose, so option A is not correct. Although the patient needs additional LDL-C reduction and has
diabetes, bile acid sequestrants should not be used when fasting triglycerides >300 mg/dL. In addition, the 2013 Cholesterol Guideline prioritizes LDL-C reduction to reduce ASCVD risk, rather than triglyceride lowering when triglycerides < 500 mg/dL.
Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2016 ACC expert consensus decision pathway on the role of non-statin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk. J Am Coll Cardiol 2016;68:92-125.
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2889-934.