Statins, fibrates valuable in heart disease treatment

July 1, 2008

Statin medications lower cholesterol levels and have an anti-inflammatory effect. They should be used in combination with lifestyle changes to reduce heart disease risk.

Studies of people with heart disease have shown that lowering cholesterol levels can reduce the risk of dying from heart disease, having a heart attack, and/or needing heart bypass surgery.

Even among people who do not have heart disease, lowering cholesterol levels can reduce the risk of developing heart disease and related deaths.

"Statins have other effects in addition to their effects on cholesterol levels," says Mark Abramowicz, MD, editor of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs. "They have an anti-inflammatory effect, and they improve the ability of blood vessels to widen. However, they should not be used as a substitute for lifestyle changes."

Currently, three statins are available as generics, however, statins differ in potency. The two most potent medications, Crestor (rosuvastatin) and Lipitor (atorvastatin), currently are not available as generics.

"When choosing a statin, a major consideration should be the magnitude of LDL-C reduction required," says Dr. Abramowicz. "If moderate lowering is needed, lovastatin, simvastatin or a low dose of atorvastatin (10 mg) would be a reasonable choice. Intense LDL-C reduction can be obtained by using atorvastatin or rosuvastatin, but clinical outcomes data are lacking for rosuvastatin. In patients with acute coronary syndromes, atorvastatin is preferred."

When statins alone do not control lipid levels, they may be combined with a number of other medications, including bile acid sequestrants, Zetia (ezetimibe), fibrates, niacin and fish oil capsules. Welchol (colesevelam) is tolerated much better than resin bile acid sequestrants and is less likely to interfere with intestinal absorption of other drugs.

For patients with low levels of high density cholesterol (HDL-C), high triglycerides and a normal LDL-C, statins combined with fenofibrate, niacin or fish oil are recommended.

"When both HDL-C and LDL-C are low in patients at risk for coronary disease, a fibrate alone, niacin alone, or a combination of niacin with a statin would be a reasonable choice," says Dr. Abramowicz. "Two fibrate preparations are available in the United States, and clinical benefit is best documented for gemfibrozil, which is available as a generic."

When taken by patients who don't have coronary disease, but do have risk factors such as high LDL-C, low HDL-C, hypertension or diabetes, pravastatin, lovastatin and Lipitor (atorvastatin) have been shown to reduce the risk of subsequent cardiovascular problems. In patients with existing heart disease, treatment with various statins lowered the incidence of heart attack and stroke, and decreased mortality from all causes, even in patients with normal LDL-C levels. Statin therapy for patients undergoing elective angioplasty reduced the rate of subsequent heart attacks by 43%, from 5.2% to 3%.

PREVENTIVE SERVICES

Health Net is rolling out a Medicare Advantage Special Needs Plan (SNP) designed for seniors with high cholesterol. While most SNPs focus on managing chronic diseases, the Sage plan focuses on prevention.

The benefits are almost identical to the plan's Medicare Advantage product, says Richard Jacobs, MD, chief medical officer and vice president of medical operations for Health Net of Arizona. "Sage is an engagement strategy. It means we don't have to waste time and resources searching for the people who have this problem. Since everyone in the plan has hypercholesterolemia, we can focus resources and attention on them."