2-Minute Consultation: Target Hyperlipidemia

Dr. LaFleur is a research assistantprofessor in the University of UtahCollege of Pharmacy PharmacotherapyOutcomes Research Center within theDepartment of Pharmacotherapy.

The leading cause of death in theUnited States—coronary arterydisease (CAD)—is also one of themost preventable.^1,2 Eating a healthydiet, exercising, and avoiding tobaccosmoke exposure can improve many CADrisk factors: obesity, physical inactivity,elevated triglycerides, low high-densitylipoprotein cholesterol, and metabolicsyndrome.³ Largely because of our failureto implement these preventive measures,more than half of us eventually willhave one of the most treatable causesand predictors of CAD—hyperlipidemia.⁴Fortunately, modern pharmaceutical sciencehas equipped us with a toolkitto help our patients stave off CAD; itincludes lipid-lowering medications andeffective goal-setting.

Step 1: Have a Specific Goal

Specific goals are more likely to improveperformance than vague goals.⁵Every patient should know his or herspecific goal for low-density lipoproteincholesterol (LDL-C) (Table 1).^3,6,7 LDL-C isthe primary treatment target in hyperlipidemia.

Table 1

LDL-C Goals

Risk Category

Description

Goal (mg/dL)

Very high risk

Existing CAD, plus major or poorlycontrolled risk factors for CAD, riskfactors for metabolic syndrome, oracute coronary syndromes

<70

High risk

Existing CAD, CAD risk equivalent, or10-year Framingham risk >20%

<100

Moderately high risk

At least 2 risk factors with 10-yearFramingham risk 10%-20%

<100 to 130

Moderate risk

At least 2 risk factors with 10-yearFramingham 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 Conceptof Self-efficacy

Self-efficacy&#8212;the belief that one hasthe power to produce the desiredeffect&#8212;is an important performancemodifier.⁸ Self-efficacy requires havingthe "right" tools (medications) and the"right" information (how to use themand what to expect). Statins capable of a30% to 40% LDL-C reduction are first-linetherapy, regardless of the patient's initialdistance from goal (Table 2).³ Answersto frequently asked patient questions includethe following:

Patients may be concerned about therisk of muscle toxicity due to reportscited in the lay press.^9,10 Tell patientsthat muscle toxicity dependson plasmadrug concentrations with all statins.¹¹ Asdoses increase, so does the risk.

All the statins except pravastatin aremetabolized by liver enzymes; drugsthat inhibit these enzymes increasetherisk of muscle toxicity.¹¹ Experts believedthat this caused the increased rate ofmuscle toxicity with fibrate/statin combinations.We now know, however, thatthe interaction is specific to gemfibrozil'sinhibition of statin glucuronidation, whichdoes not happen with fenofibrate.¹¹

3. Patients may have read about theEzetimibe and Simvastatin in HypercholesterolemiaEnhances AtherosclerosisRegressiontrial in the news.¹² This studyshowed that ezetimibe in combinationwith a statin did not reduce coronaryartery plaques,compared with a statinalone. Ezetimibe still can help patientsreach their LDL-C goal in combinationwith a statin, however.

Table 2

The Right Tools: StandardDoses* for Statins

Agent andDose (mg/day)

LDL-CReduction (%)

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 aLDL-C reduction of 30%-40%.

LDL-C = low-density lipoprotein cholesterol.

Adapted from reference 3.

Step 3: Get Feedback

Feedback enhances performance.⁵ Encourageyour patients to seek a followupfasting lipid panel every 6 weeks afterbeginning treatment until they reachgoal.¹³ Inform your patients that every1% reduction in LDL-C reduces their riskof having a major CAD event by 1%.³

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

References

• 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.
• 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.
• 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.
• 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.
• Locke EA. Motivation through conscious goal setting. Appl Prev Psychol. 1996;5:117-124.
• 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.
• 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.
• 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.
• 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.
• 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.
• Sisson EM. Dyslipidemias: Therapeutic advances. In: Dunsworth TS, Richardson MM, eds. Pharmacotherapy Self-Assessment Program (PSAP). Lenexa, KS: American College of Clinical Pharmacy; 2007.
• 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.
• 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.