a. add Zetia 10mg/day
b. change Lipitor to Crestor
c. add Niacin
d. add another statin
The first thing one should do is ensure the patient is taking the medication correctly and adhering to a strict diet and exercise regiment. The next step would be to try a more potent statin (Crestor).
Zetia has been show to decrease LDL by 14-17% when combined with a statin, however there is no evidence that addition of Zetia has any effect on mortality or cardiovascular outcomes.
Zetia has been show to decrease LDL by 14-17% when combined with a statin, however there is no evidence that addition of Zetia has any effect on mortality or cardiovascular outcomes.
The ENHANCE trial randomized patients to simvastatin 80mg with or without ezetimbide
10mg daily. Combination therapy provided a significant LDL decrease and HDL
increase. However, there was no difference in primary outcome
of carotid intima-media thickness or cardiovascular events. The ARBITER 6-HALTs trial took patients with CHD or CHD equivalents who were
already on statins and randomized them to niacin or ezetimibide.
Addition of Niacin had better outcomes then addition of ezetimibide. We already know
from the AIM-HIGH trial that niacin really provides no benefit in
patients already on a statin. Thus, all this data seems to suggest that the addition of ezetimibe does not provide clinical benefit. Additionally, ezetimibe has some potential concerning side effects including a possible cancer link that was noted the SEAS trial.
In the absence of an indication other than prevention of CHD, do not
treat patients with another lipid-lowering medication in combination
with a statin even if the LDL-C is not at goal. There is a theory that the actual statin itself is more important than the LDL goal. Some advocate only adding on a second lipid lowering agent if the LDL is still greater then 160.
The ATP 4 committee is actually discussing this issue right now and we asked our expert for insider information. Unfortunately, it is classified, so all we can advise is that it is a grade E recommendation (ie: expert opinion but little or no data to support it) to consider adding a second class of lipid lowering drugs in select patients.
The ATP 4 committee is actually discussing this issue right now and we asked our expert for insider information. Unfortunately, it is classified, so all we can advise is that it is a grade E recommendation (ie: expert opinion but little or no data to support it) to consider adding a second class of lipid lowering drugs in select patients.
Statins are the only lipid lowering class of drugs to demonstrate clear improvements in overall mortality in primary and secondary prevention. It is reasonable to try a different statin as you may see better results and Crestor is more potent then lipitor.
