High LDL and High Triglycerides

I've talked about the main cholesterol problem that affects people: high LDL levels. Although the numbers vary according to age, gender, and ethnic background, about 5 percent to 10 percent of people with this problem are also plagued by another: high triglyceride levels.

In these people, triglyceride levels are typically in the 300–600 range. In one landmark study of heart disease risk published more than thirty years ago, it was this combination lipid disorder that was the most commonly seen lipid abnormality in younger individuals who had experienced a heart attack.

This combination lipid disorder is more dangerous than elevated triglyceride or LDL level alone. In people with this duo of problems, poor lifestyle choices are often to blame. The same factors that raise the LDL or triglyceride level in isolation should be carefully reviewed in someone who has an elevation in both.

With proper attention to those issues, it is possible to treat the whole lipid disorder without medication or to at least solve one of the problems, which makes therapy easier. Sometimes, though, a genetic problem can cause VLDL particles, which normally turn to LDL particles as their triglycerides are extracted for energy use, to get stuck in the middle.

Like VLDL particles, these intermediate-density lipoproteins (IDL) are high in triglycerides, but they also have a relatively high content of cholesterol. So individuals with this genetic problem appear to have a combined lipid disorder (too much VLDL and LDL), when in fact they have an abnormal accumulation of IDL.

If lifestyle therapies can’t correct the problem, most people with a combination of high triglycerides and LDL cholesterol get started on a fibrate drug. Most of the time, they also need a statin to get their lipoproteins to desirable levels. (Some doctors prefer to reverse this order of drug use, starting with a statin and then adding a fibrate.)

Though this combination of medications is very effective at getting both triglycerides and LDL levels under control, it can exacerbate the main side effect of statins—the muscle damage known as rhabdomyolysis that can lead to kidney failure and, very rarely, death.

In any case, you shouldn’t let that potential problem stop you from taking this combination if your doctor recommends it—the risks of having high triglycerides combined with high LDL levels are too great. However, you should be aware of this possible side effect and be on the lookout for muscle aches, the first sign that there’s a problem.

The muscle aches feel similar to postworkout aches and generally affect the larger muscles of the body, like the buttocks, thighs, calves, and shoulders. They may progress to muscle weakness that stops you from normal activities like climbing stairs, or muscles that hurt when you touch or squeeze them.

If you feel any dull pain or achiness in your muscles that can’t be explained by exercise you’ve done, stop taking the medications and call your doctor immediately. He or she will generally take you off the medications for a few days. If your muscle aches stop, you’ll probably be prescribed a new statin with the same fibrate and told to be vigilantly on the lookout for muscle aches.

When the muscle breakdown known as rhabdomyolysis is occurring, the body releases more of a protein called creatine kinase. Though there is a test for this protein, as I discuss on page 152, I don’t think testing for it is generally very useful in deciding if lipid drugs are safe to use.

The best way to do that is to be on the lookout for muscle aches. However, if you were to develop significant muscle breakdown as a result of statin-fibrate combination therapy, the CPK level would be elevated and is useful in helping your doctor decide the severity of the injury and what kind of treatment you need.

Many people with muscle aches caused by a single statin or a statin-fibrate combination find that the aches occur only with certain statins. In fact, this is what happened in my case. I was on a plane flying to a medical conference when I noticed an achiness in my hips that I couldn’t attribute to anything.

Because I was newly taking a statin at the time to control my rising cholesterol levels, I immediately thought about all the patients I had treated who had voiced a similar complaint. I stopped taking the drug, and the muscle aches stopped almost immediately.

When I switched to a different statin, they never came back. For some people, though, all of the statins cause the same achiness. In these cases, the safest thing to do is to take a different cholesterol-lowering drug, such as ezetimibe or niacin.

For individuals on combined therapy with a statin and a fibrate, it is perfectly reasonable to continue the fibrate and swap the statin for niacin or ezetimibe. Note, though, that these combinations usually reduce LDL levels much less than the statin-fibrate pair, which is why it’s important to try several different statins first.