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Test Your Knowledge |
Question: Is raising the statin dose better than adding a second drug? Barbara
A. 56 y/o white female with type 2 diabetes on Avandia 8 mg., Zocor 20mg.,
Vasotec 20mg, and Metformin 1000mg. Has
an A1c of 8.5% and Total Cholesterol of 260, LDL 158, HDL of 35 and
Triglycerides of 200. What
would the first choice be?
Statins are recommended for initial therapy. But you get the maximum effect at starting doses...simvastatin 20 mg...pravastatin 20 mg...etc. As
a rule, doubling the statin dose reduces LDL only about 6% more.
It's usually more effective to add a second drug.
Adding a bile acid sequestrant (cholestyramine, colestipol,
colesevelam) lowers LDL about 10% to 20%. Adding
the new cholesterol absorption blocker, Zetia (ezetimibe), lowers
LDL about 15%. There
are different estimates. The numbers vary a lot...depending on patient
variables...study design...marketing spin. Keep
in mind that adding a second drug is more expensive...sometimes adds side
effects...and might reduce compliance. References 1.
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(19):2486-97. 2.
McKenney J. Combination therapy for elevated low-density lipoprotein
cholesterol: the key to coronary artery disease risk reduction. Am
J Cardiol 2002;90(Suppl):8K-20K. 3.
Rosenson RS. The rationale for combination therapy. Am
J Cardiol 2002;90(suppl):2K-7K. 4.
Grundy SM. Alternative approaches to cholesterol lowering therapy. Am
J Cardiol 2002;90(10):1135-38. 5.
Pearson TA, Laurora I, Chu H, et al. The Lipid Treatment Assessment
Project (L-TAP): a multicenter survey to evaluate the percentages of
dyslipidemic patients receiving lipid-lowering therapy and achieving low-density
lipoprotein cholesterol goals. Arch
Intern Med 2000;160:459-67. 6.
Xydakis AM, Ballantyne CM. Combination therapy for combined dyslipidemia.
Am
J Cardiol 2002;90(suppl):21K-29K.
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