Therapeutic lifestyle modification is the most appropriate therapy for this patient. Lifestyle modification is an essential element of treatment for all patients with elevated lipid parameters but is the primary therapy in those with hyperlipidemia without clinical atherosclerotic cardiovascular disease (ASCVD), diabetes mellitus, elevation of LDL cholesterol greater than 190 mg/dL (4.92 mmol/L), or elevated 10-year risk for developing ASCVD. The 2013 American Heart Association/American College of Cardiology lifestyle management guideline strongly recommends that adults who would benefit from LDL cholesterol lowering (1) consume a diet that emphasizes vegetables, fruits, and whole grains, and limits intake of sweets and red meats; (2) aim for a dietary intake of 5% to 6% of calories from saturated fat; and (3) reduce the percentage of calories from saturated fat and trans fat. Moderate-strength recommendations include performing aerobic physical activity (three to four sessions per week, with an average of 40 minutes per session, and involving moderate- to vigorous-intensity physical activity) to lower LDL cholesterol level, non-HDL cholesterol level, and blood pressure.

Ezetimibe is not recommended as first-line therapy for hyperlipidemia in patients with an indication for treatment, as there are insufficient data on the efficacy of ezetimibe in reducing ASCVD risk. There is also no indication for its use in patients at low risk.

In patients without clinical ASCVD or diabetes, statin therapy is typically reserved for those with an LDL cholesterol level of 190 mg/dL (4.92 mmol/L) or higher or an estimated 10-year risk of ASCVD of 7.5% or higher. The benefits of statin therapy in healthy patients with an LDL cholesterol level lower than 190 mg/dL (4.92 mmol/L) are not established. In this patient, treatment with neither high-intensity statin therapy nor moderate-intensity statin therapy would be appropriate.

Although niacin has several favorable effects on lipids, it is less effective than statin drugs in preventing ASCVD and is also not recommended as first-line therapy for patients with an indication for treatment. It would also not be appropriate treatment for this patient who does not have a clear indication for pharmacologic lipid-lowering therapy.