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2-Minute Consultation: Target Hyperlipidemia

Joanne LaFleur, PharmD, MSPH
Published Online: Monday, September 1, 2008   [ Request Print ]


Dr. LaFleur is a research assistant professor in the University of Utah College of Pharmacy Pharmacotherapy Outcomes Research Center within the Department of Pharmacotherapy.


The leading cause of death in the United States—coronary artery disease (CAD)—is also one of the most preventable.1,2 Eating a healthy diet, exercising, and avoiding tobacco smoke exposure can improve many CAD risk factors: obesity, physical inactivity, elevated triglycerides, low high-density lipoprotein cholesterol, and metabolic syndrome.3 Largely because of our failure to implement these preventive measures, more than half of us eventually will have one of the most treatable causes and predictors of CAD—hyperlipidemia.4 Fortunately, modern pharmaceutical science has equipped us with a toolkit to help our patients stave off CAD; it includes lipid-lowering medications and effective goal-setting.

Step 1: Have a Specific Goal

Specific goals are more likely to improve performance than vague goals.5 Every patient should know his or her specific goal for low-density lipoprotein cholesterol (LDL-C) (Table 1).3,6,7 LDL-C is the primary treatment target in hyperlipidemia.

Table 1
LDL-C Goals

Risk Category

Description

Goal (mg/dL)

Very high risk

Existing CAD, plus major or poorly controlled risk factors for CAD, risk factors for metabolic syndrome, or acute coronary syndromes

<70

High risk

Existing CAD, CAD risk equivalent, or 10-year Framingham risk >20%

<100

Moderately high risk

At least 2 risk factors with 10-year Framingham risk 10%-20%

<100 to 130

Moderate risk

At least 2 risk factors with 10-year Framingham risk <10%

<130

Low risk

0-1 risk factors

<160

LDL-C = low-density lipoprotein cholesterol; CAD = coronary artery disease.
Adapted from references 3,6,7.


Step 2: Apply the Concept of Self-efficacy

Self-efficacy—the belief that one has the power to produce the desired effect— is an important performance modifier.8 Self-efficacy requires having the "right" tools (medications) and the "right" information (how to use them and what to expect). Statins capable of a 30% to 40% LDL-C reduction are first-line therapy, regardless of the patient's initial distance from goal (Table 2).3 Answers to frequently asked patient questions include the following:

Patients may be concerned about the risk of muscle toxicity due to reports cited in the lay press.9,10 Tell patients that muscle toxicity depends on plasma drug concentrations with all statins.11 As doses increase, so does the risk.

All the statins except pravastatin are metabolized by liver enzymes; drugs that inhibit these enzymes increase the risk of muscle toxicity.11 Experts believed that this caused the increased rate of muscle toxicity with fibrate/statin combinations. We now know, however, that the interaction is specific to gemfibrozil's inhibition of statin glucuronidation, which does not happen with fenofibrate.11

3. Patients may have read about the Ezetimibe and Simvastatin in Hypercholesterolemia Enhances Atherosclerosis Regression trial in the news.12 This study showed that ezetimibe in combination with a statin did not reduce coronary artery plaques, compared with a statin alone. Ezetimibe still can help patients reach their LDL-C goal in combination with a statin, however.

Table 2
The Right Tools: Standard Doses* for Statins

Agent and Dose (mg/day)

LDL-C Reduction (%)

Atorvastatin 10

39

Fluvastatin 40-80

25-35

Lovastatin 40

31

Pravastatin 40

34

Rosuvastatin 5-10

39-45

Simvastatin 20-40

35-41

*Standard doses are those that result in a LDL-C reduction of 30%-40%.
LDL-C = low-density lipoprotein cholesterol.
Adapted from reference 3.


Step 3: Get Feedback

Feedback enhances performance.5 Encourage your patients to seek a followup fasting lipid panel every 6 weeks after beginning treatment until they reach goal.13 Inform your patients that every 1% reduction in LDL-C reduces their risk of having a major CAD event by 1%.3

For more information about CAD risk factors, visit the National Heart, Lung, and Blood Institute's Web site at www.nhlbi.nih.gov/health/index.htm.


References

  1. Centers for Disease Control and Prevention. Leading causes of death in males: United States, 2004. www.cdc.gov/men/lcod.htm. Accessed February 23, 2008.
  2. Centers for Disease Control and Prevention. Leading causes of death in females: United States, 2004. www.cdc.gov/women/lcod.htm. Accessed February 23, 2008.
  3. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227-239.
  4. Genest JJ, McNamara JR, Ordovas JM, et al. Lipoprotein cholesterol, apolipoprotein A-I and B and lipoprotein (a) abnormalities in men with premature coronary artery disease. J Am Coll Cardiol. 1992;19:792-804.
  5. Locke EA. Motivation through conscious goal setting. Appl Prev Psychol. 1996;5:117-124.
  6. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285:2486-2497.
  7. Fedder DO, Koro CE, L'Italien GJ. New National Cholesterol Education Program III guidelines for primary prevention lipid-lowering drug therapy: projected impact on the size, sex, and age distribution of the treatment-eligible population. Circulation. 2002;105:152-156.
  8. Lathem G, Locke EA. Building a practically useful theory of goal setting and task motivation. A 35-year odyssey. Am Psychol. 2002;57:705-717.
  9. Public Citizen Health Research Group. Petition to the FDA to remove the cholesterol-lowering drug rosuvastatin (CRESTOR) from the market (HRG Publication #1693). www.citizen.org/publications/release.cfm?ID=7305. Accessed February 27, 2008.
  10. Public Citizen Health Research Group. Letter to FDA shows that Crestor has higher rates of rhabdomyolysis compared to other statins (HRG Publication #1729). www.citizen.org/publications/release.cfm?ID=7370. Accessed February 27, 2008.
  11. Sisson EM. Dyslipidemias: Therapeutic advances. In: Dunsworth TS, Richardson MM, eds. Pharmacotherapy Self-Assessment Program (PSAP). Lenexa, KS: American College of Clinical Pharmacy; 2007.
  12. Kastelein JJ, Sager PT, de Groot E, Veltri E. Comparison of ezetimibe plus simvastatin versus simvastatin monotherapy on atherosclerosis progression in familial hypercholesterolemia. Design and rationale of the Ezetimibe and Simvastatin in Hypercholesterolemia Enhances Atherosclerosis Regression (ENHANCE) trial. Am Heart J. 2005;149:234-239.
  13. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143-3421.
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