Mitchel L. Zoler, editor Bruce Jancin, writer
Current consensus is that virtually everyone with known coronary disease ought to be on an HMG-CoA reductase inhibitor, regardless of LDL cholesterol level. These well-studied drugs, commonly known as statins, cut risk by lowering LDL cholesterol and through anti-inflammatory and plaque-stabilizing effects.
The Adult Treatment Panel III Report guidelines of the National Cholesterol Education Program (NCEP) also recommend statins for all patients who have diabetes, peripheral artery disease, and other conditions placing an individual at very high risk for coronary events. The LDL cholesterol treatment goal is in flux. The existing NCEP recommendation is that drug therapy be reserved for patients with an LDL level above 100 mg/dL. But some experts are now comfortable driving LDL levels to 70 mg/dL or less, especially in a patient who's had a coronary event despite a modest LDL level.
Experts frequently use combination drug therapy for secondary coronary event prevention, mainly in patients who have a mixed hyperlipidemia featuring a low HDL level and elevated triglycerides, those with a modest LDL response to statins, and patients with familial hypercholesterolemia and very high cholesterol levels. Combinations consisting of a statin and niacin are the most popular, but combinations of a statin and a fibrate or a statin and a bile acid sequestrant are also used. The lipidmodifying effects of combination therapy are additive, with evidence of markedly enhanced risk reduction. Triple-drug and occasionally quadruple-drug therapy is warranted in patients with familial hypercholesterolemia and very high LDL levels.
Marketing approval is anticipated soon for two new agents: rosuvastatin (Crestor), a drug that, like atorvastatin, lies at the high end of the LDL-lowering potency spectrum, and ezetimibe (Zeria). Ezetimibe is drawing considerable interest because of its unique mechanism of action--it affects cholesterol transport in the gut--and because in combination with a statin, it results in a further 18%-20% LDL level reduction, equivalent to a threefold boost in a patient's statin dose.
Ali lipid-modifying drugs are safe in the elderly without the need for dosage reductions. Because of insufficient safety data in pregnant and breast-feeding women, prudence dictates a 1- to 2-year drug holiday in what is otherwise lifelong therapy.
COPYRIGHT 2002 International Medical News Group
COPYRIGHT 2002 Gale Group
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