Craig I. Coleman, PharmD
Dr. Coleman is an assistant professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy.
AL is a 65-year-old man with high cholesterol who comes to the pharmacy counter to refill his prescription for rosuvastatin. He mentions how his physician wanted to start him on this “new medication” called Trilipix because his triglyceride levels are still not where they should be. He complains that he is already taking too many drugs for his high cholesterol and asks, “Can I just take more of the one I’m on?” The pharmacist reviews AL’s drug profile and sees that he is currently taking rosuvastatin 20 mg daily.
What should the pharmacist tell AL about Trilipix and why his physician wants to add it?
CC is a 17-year-old teenager previously diagnosed with intermittent asthma (infrequent symptoms, usually occurring twice weekly at most) who complains to his family physician of now experiencing daily asthma-like symptoms, almost always requiring the use of his albuterol inhaler. He also tells his physician that over the past 12 months he has gone to the emergency department twice because of shortness of breath, each time resulting in a course of treatment with oral prednisone.
What classification of asthma does CC now present with? How should CC’s pharmacologic asthma treatment be altered based upon this new information?
The pharmacist should tell AL that Trilipix (fenofibric acid) sustained release is the first FDA-approved fibrate for use in combination with a statin for cholesterol management. Because AL is already taking a moderate dose of rosuvastatin, it is unlikely that doubling the dose to 40 mg daily would yield as much triglyceride-lowering efficacy as adding a new drug like Trilipix. Studies of Trilipix in combination with a low-to-moderate dose of a statin have demonstrated significant lowering of triglycerides (18%-27% over a statin alone), another “bad” type of cholesterol that has been associated with heart disease when elevated, and also can increase high-density lipoprotein cholesterol or “good” cholesterol (9%-11% over a statin alone). The pharmacist should reassure AL that Trilipix when added to a statin is safe and effective, but that he should report any unexplained muscle pain, tenderness, or weakness, as they may be signs of a serious side effect (rhabdomyolysis) that requires immediate attention.
According to the most recent National Asthma Education and Prevention Program (NAEPP) guidelines released in 2007 (www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm), CC can be diagnosed with moderate persistent asthma based upon his level of impairment (daily symptoms requiring short-acting beta2 agonist rescue) and his risk for significant exacerbations (.2/year). The NAEPP guidelines recommend a 6-step approach to treating asthma. Patients with moderate persistent asthma typically are treated at step 3, which entails the use of a medium dose of inhaled corticosteroid (ICS) or a low dose of ICS plus a long-acting beta2 agonist (LABA) as preferred therapies. Of note, the equal weighting of the medium-dose ICS and combination ICS/LABA recommendations are new to the 2007 NAEPP guidelines and came about as a result of a large clinical trial demonstrating a small but important increased risk of asthma-related deaths with salmeterol use.