RB is a new patient who presents to your pharmacotherapy clinic for medication management. He is a 52-year-old Caucasian male with a PMH of type 2 diabetes, hypertension, hyperlipidemia, and COPD. He is a former smoker who quit 7 years ago. RB says he has been adherent with his medication. His current medications and most recent labs are below.

Medications: 

Metformin 500mg PO BID

Losartan 50mg PO daily

Trelegy Ellipta 100mcg/62.5mcg/25mcg 1 puff daily

Rosuvastatin 10mg PO QHS

Labs:

BP 128/79 mmHg

Total Cholesterol: 185 mg/dL

LDL: 140 mg/dL

HDL: 40 mg/dL

HbA1c: 7%

10-year ASCVD risk: 10.4%

Which of the following would be the most appropriate action to take regarding RB’s lipid therapy? 

A. Switch to atorvastatin 20mg PO QHS and repeat a lipid panel in 6 months

B. Switch to simvastatin 20mg PO QHS and repeat a lipid panel in 12 months

C. Increase to rosuvastatin 20mg PO QHS and repeat a lipid panel in 1 month

D. Switch to ezetimibe 10mg PO daily and repeat a lipid panel in 6 weeks

Answer with Rationale

LDL-C is a primary cause of atherosclerosis; however, there are other contributors to increased ASCVD risk, such as advanced age, smoking, hypertension, and dysglycemia. The ASCVD 10-year risk score is a useful tool in determining which patients would benefit from statin therapy and how intense their statin therapy should be. The 2018 ACC/AHA hyperlipidemia guidelines provide specific guidance on when to use low-, moderate-, or high-intensity statins based on patient-specific factors, including their ASCVD risk score. The ASCVD risk score is only calculated for patients who have not had a cardiovascular event. Patients who have already experienced an event automatically qualify for a high-intensity statin for secondary prevention.

Statins prevent the conversion of HMG-CoA to mevalonic acid through inhibition of HMG-CoA reductase. By blocking this crucial step in cholesterol synthesis, statins decrease the production of cholesterol and increase the expression of LDL receptors, which is the primary mechanism for lowering LDL-C levels. Lowering LDL-C levels reduces the risk of heart attack, stroke, and cardiovascular death. The lower the LDL, the better! In addition, statins have pleiotropic effects such as plaque stabilization that are independent of their LDL lowering effects.

Answer A is incorrect. Atorvastatin 20mg is a moderate-intensity statin, and RB is already on moderate-intensity therapy with rosuvastatin 10mg.  In adults 40-75 years old with diabetes and a 10-year ASCVD risk score of 7.5-19%, the ACC/AHA guidelines recommend ≥ 50% reduction in LDL-C and LDL-C < 100 mg/dL. With this in mind, RB’s LDL-C is 140 mg/dL and not currently at goal. Furthermore, the ACC/AHA guidelines recommend repeating a lipid panel in 4-12 weeks if any medication changes are made or 1 year if no changes are made. 

Answer B is incorrect. Simvastatin 20mg is a moderate-intensity statin, and RB is already on moderate- intensity therapy with rosuvastatin 10mg. In adults 40-75 years old with diabetes and a 10-year ASCVD risk score of 7.5-19%, the ACC/AHA guidelines recommend ≥ 50% reduction in LDL-C and LDL-C < 100 mg/dL. With this in mind, RB’s LDL-C is 140 mg/dL and not currently at goal. Furthermore, the ACC/AHA guidelines recommend repeating a lipid panel in 4-12 weeks if any medication changes are made or 1 year if no changes are made. 

Answer C is correct. The ACC/AHA guidelines recommend high-intensity statin therapy for primary prevention in patients who are 40-75 years old with diabetes and a 10-year ASCVD risk score of 7.5-19%. A dose of rosuvastatin 20mg daily would represent a high-intensity statin regimen and would represent the most appropriate change needed for RB with an appropriate follow-up for a lipid panel. 

Answer D is incorrect. Ezetimibe lowers LDL-C by about 20% in comparison to a 25-50% LDL reduction seen with high-intensity statins. Ezetimibe should be used in combination with a statin for further LDL lowering in patients who don't respond at lower statin doses or who cannot tolerate high intensity statin doses due to musculoskeletal side effects. 

Brand/generic: atorvastatin (Lipitor); ezetimibe (Zetia); fluticasone furoate, umeclidinium, and vilanterol (Trelegy Ellipta); losartan (Cozaar); metformin (Glumetza, Riomet); rosuvastatin (Crestor); simvastatin (Zocor)

NAPLEX Content Domains Covered:

1.A.1 Pharmacology

1.A.2 Pharmacodynamics

2.A.2 Indications, usage, and dosing regimens

2.A.5 Safety and effectiveness 

3.C.2 Appropriateness of therapy

3.D.1 Therapeutic goals, clinical endpoints, and follow-up