Pharmacotherapy Case: Dyslipidemia Management by Dr. Nehad Jaser

Age: 55 years

Gender: Male

Subjective Data

Chief Complaint:

“I stopped taking my cholesterol medication because it makes my muscles ache.”

History of Present Illness:

Mr. Johnson is a 55-year-old male with a history of hypertension, obesity, and dyslipidemia diagnosed 2 years ago. He was initially prescribed atorvastatin 40 mg daily but self-discontinued it 3 months ago due to diffuse myalgias. He reports persistent fatigue and occasional chest discomfort on exertion but denies palpitations, shortness of breath, or syncope. He expresses concern about his cholesterol levels and fears another heart attack, as his father had a myocardial infarction at age 58.

Medical History:

• Hypertension (diagnosed 10 years ago, poorly controlled)

• Obesity (BMI 32 kg/m²)

• Dyslipidemia (baseline LDL 160 mg/dL, HDL 35 mg/dL, triglycerides 250 mg/dL)

Family History:

• Father: Myocardial infarction at 58, hyperlipidemia.

• Mother: Type 2 diabetes, stroke at 70.

Social History:

• Sedentary lifestyle (desk job, minimal exercise).

• Diet high in processed foods and saturated fats.

• Former smoker (1 pack/day for 15 years, quit 5 years ago).

• Occasional alcohol (2–3 beers/week).

Medications:

• Lisinopril 10 mg PO daily (hypertension)

• No current lipid-lowering therapy (stopped atorvastatin 3 months ago)

Allergies:

• No known drug allergies.

Adherence:

• Non-adherent to statin due to side effects; otherwise >80% adherent to lisinopril.

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Objective Data

Vital Signs:

• BP: 148/92 mmHg

• HR: 82 bpm

• RR: 16 breaths/min

• Weight: 98 kg

• Height: 175 cm

• BMI: 32 kg/m²

Physical Exam:

• Cardiovascular: Regular rate and rhythm, no murmurs.

• Musculoskeletal: No tenderness or weakness on palpation; normal range of motion.

• Skin: No xanthomas or xanthelasma.

Laboratory Results:

• LDL: 178 mg/dL (↑ from 160 mg/dL)

• HDL: 38 mg/dL

• Triglycerides: 280 mg/dL

• ALT: 45 U/L (normal)

• CK: 150 U/L (normal)

Diagnostics:

• Lipid panel: Consistent with mixed dyslipidemia (elevated LDL and triglycerides, low HDL).

• ASCVD 10-Year Risk Score: 15% (high risk due to age, hypertension, smoking history, and LDL).

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Assessment

1. Primary Hyperlipidemia:

   • LDL 178 mg/dL (goal <70 mg/dL for ASCVD high-risk patients).

   • Triglycerides 280 mg/dL (goal <150 mg/dL).

2. Statin Intolerance:

   • Likely statin-associated muscle symptoms (SAMS) with prior atorvastatin.

3. ASCVD Risk:

   • High risk (10-year risk ≥7.5%), necessitating aggressive LDL lowering.

4. Hypertension:

   • Poorly controlled (BP 148/92 mmHg; goal <130/80 mmHg).

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Plan

1. Pharmacotherapy:

   • Statin Rechallenge: Initiate rosuvastatin 10 mg PO daily (lower-intensity statin to minimize myalgia risk).

   • Add-on Therapy: Ezetimibe 10 mg PO daily if LDL remains >70 mg/dL after 6 weeks.

   • Hypertension: Increase lisinopril to 20 mg PO daily; recheck BP in 2 weeks.

2. Monitoring:

   • Lipid panel in 6 weeks.

   • CK and ALT at 6 weeks (if myalgias recur).

   • Annual renal function and liver enzymes.

3. Education:

   • Take rosuvastatin in the evening with food to reduce side effects.

   • Report persistent muscle pain, dark urine, or jaundice immediately.

   • Emphasize heart-healthy diet (low saturated fat, high fiber) and gradual exercise (30 min/day walking).

4. Lifestyle Modifications:

   • Refer to dietitian for Mediterranean diet counseling.

   • Encourage smoking cessation maintenance and alcohol moderation.

5. Follow-Up:

   • Return in 6 weeks for lipid recheck and symptom assessment.

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Rationale:

• Rosuvastatin was selected over atorvastatin due to its lower incidence of muscle-related side effects.

• Ezetimibe is added per ACC/AHA guidelines if LDL remains above goal on maximally tolerated statin.

• BP Control is prioritized to reduce ASCVD risk, aligning with a target of <130/80 mmHg for high-risk patients.

• Lifestyle interventions address obesity and metabolic drivers of dyslipidemia.