How should I manage a 62-year-old Hispanic man who has hyperlipidemia and abnormal liver enzymes? The patient’s most recent lab studies showed total cholesterol 326 mg/dL, LDL 233 mg/dL, triglycerides 262 mg/dL, HDL 41 mg/dL, total cholesterol-to-HDL ratio 8.0; LDL-to-HDL ratio 5.7. Liver enzymes were aspartate aminotransferase 62 IU/L, alanine aminotransferase 95 IU/L, &-gamma;glutamyltransferase 104 IU/L. A hepatitis panel is negative. He does not use alcohol or illicit drugs. Current daily medications include glipizide XL 5 mg daily, lisinopril/hydrochlorothiazide 20 mg/12.5 mg, and verapamil 300 mg. An abdominal sonogram showed hepatomegaly and fatty infiltration.
—Tony Pham, DO, Dallas

This patient needs his LDL lowered and soon! Based on the description, a fatty liver is probably responsible for the enzyme elevations, which are relatively minor but may well increase if a statin is used. Nevertheless, a statin trial is worthwhile. If the enzyme levels do not exceed two to three times normal (a range not considered evidence of hepatotoxicity [Am J Cardiol. 2002;89:1374-1380]) with a small dose (10 mg) of atorvastatin (Lipitor), then you have successfully achieved the first component of the patient’s antilipid therapy without harming him. Assuming there is still LDL elevation after low-dose statin treatment, I would not push the dose higher but rather add ezetimibe (Zetia) to achieve a target LDL ≤100 mg/dL.
—Peter F. Cohn, MD (103-5)

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