Making Best Practice, Every Day Practice
The benefits of lowering low-density lipoprotein (LDL) cholesterol with statin therapy for cardiovascular disease (CVD) prevention are well established. Recent guidelines from the National Institute for Health and Clinical Excellence (NICE) have emphasised the importance of achieving lower lipid levels, by adopting targets of 4 mmol/L for total cholesterol and 2 mmol/L for LDL cholesterol […]
What is the clinical trial evidence for the benefits of long-term statin therapy?Alan Begg
Structured monitoring of patients with long-term conditions has become a major component of scheduled care and a GP’s workload. The length of time a patient should remain on a certain medication to prevent a further cardiovascular event is often controversial, and phrasing recommendations to reflect the often absent evidence base is a problem for guideline writers. Recommendations on length of treatment are often informed by the results of randomised trials carried out for a limited period of time rather than reflecting long-term use in a defined patient cohort. This review reflects on the clinical trial evidence for long-term statin treatment in both primary and secondary prevention.
*The British Journal of Primary Care Nursing approached Abbott Healthcare Products Limited to fund the production of this supplement. The company was not involved in its development, although it was asked to review it for technical accuracy just prior to printing. Editorial control has remained with the British Journal of Primary Care Nursing at all times.
*The British Journal of Primary Care Nursing approached Merck Sharp & Dohme Limited to fund the production of this supplement following a meeting the company supported at the Primary Care Cardiovascular Society (PCCS) Conference 2009. The company was not involved in development, although it was asked to review the supplement for technical accuracy just prior to printing. Editorial control has remained with the British Journal of Primary Care Nursing at all times.
Tredaptive (nicotinic acid/laropiprant) has been launched as a new treatment option for dyslipidaemia. It is indicated for patients with combined mixed dyslipidaemia or primary hypercholesterolaemia, and should be used in combination with a statin when the cholesterol-lowering effect of statin monotherapy is inadequate, or as monotherapy when statins are considered inappropriate or not tolerated.
An efficacy study showed that treatment with the drug, with or without a statin, lowered LDL-C levels by 18% and triglycerides by 26% and raised HDL-C levels by 20% (placebo-adjusted) for a 24-week period. “Many patients do not achieve sufficient LDL cholesterol lowering on a statin alone and a significant CVD residual risk remains in some patients,” commented Dr Marc Evans, Consultant Diabetologist, Llandough. “Furthermore, low HDL-C and high triglyceride levels also contribute to cardiovascular risk and are particularly prevalent in certain patient groups, such as those with diabetes and people of South Asian origin,” he added.
Dr Evans considered that a new treatment option that can address the wider lipid profile is welcome, and will be particularly useful for secondary prevention patients and those patients with dyslipidaemia at ‘high risk’. Nicotinic acid has been widely recognised as an effective lipid-modifying therapy for over 50 years, but its use has been limited due to a flushing sideeffect. The laropiprant component in Tredaptive is an anti-flushing agent. Treatment with Tredaptive is associated with significantly lower percentages of patients with moderate or greater flushing than extended-release nicotinic acid, and any flushing that does occur subsides over time, according to trials. This reduction in flushing has led to patients on Tredaptive being less likely to discontinue treatment due to flushing compared to those on extended-release nicotinic acid (10.2% vs 22.2%, respectively; p <0.001).
Tredaptive contains 1,000 mg of nicotinic acid and 20 mg of laropiprant in each tablet. The starting dose is one tablet once a day. After four weeks, it is recommended that patients be advanced to the maintenance dose of 2,000 mg/ 40 mg taken as two tablets once daily.
Tredaptive: treating raised LDL-cholesterol and beyondGeorge Kassianos
Significant reductions in cardiovascular risk have been achieved over the past 20 years using statins to reduce levels of low-density lipoprotein (LDL) cholesterol and total cholesterol. However, there is growing evidence that managing only this lipid fraction may not optimally reduce patients’ CVD risk, particularly in those with type 2 diabetes or the metabolic syndrome. Low levels of high-density lipoprotein (HDL) cholesterol and raised triglycerides are important, but often overlooked, elements of the dyslipidaemic profile that commonly occur in these patients. Tredaptive offers the potential for reaching optimal nicotinic acid dosage and thereby a convenient option for achieving significant improvements on all three fronts of lipid modification – LDL cholesterol, HDL cholesterol and triglycerides, primarily because of significant reduction in the most troublesome sideeffect of nicotinic acid, facial flushing.
David Sciberras, Victor Robinson, Neville Calleja
: Previous research has shown that routine monitoring appears to add little to the prognostication of incipient statininduced myotoxicity (SIM) in the primary care setting. In view of this, and the fact that there are now millions of patients on statins, it seems of practical value to delve deeper into the symptomatology of SIM. : To estimate the prevalence of SIM in statin users as compared to non-users, and whether family practice is the ideal setting to identify SIM.
By focusing on total cholesterol alone, primary care is guilty of not going far enough to address cardiovascular residual risk. Through extensive landmark clinical studies, the use of statins to reduce the level of low-density lipoprotein cholesterol (LDL-C) and the risk of cardiovascular events has been demonstrated unequivocally, and now the treatment makes up the […]
Lowering LDL cholesterol (LDL-C) with statins for the prevention of cardiovascular disease (CVD) has rightly become a core activity for primary care health professionals. However, despite effective lowering of LDL-C, many patients still suffer cardiovascular events. Experts have called this ‘the residual risk’ and have speculated whether further cardiovascular events can be prevented by attention to other lipoprotein fractions, particularly HDL cholesterol (HDL-C).
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