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The effect of statin therapy in combination with ezetimibe on circulating C-reactive protein levels: a systematic review and meta-analysis of randomized controlled trials. Inflammopharmacology 2022; 30:1597-1615. [DOI: 10.1007/s10787-022-01053-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 08/08/2022] [Indexed: 12/14/2022]
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2
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Abushanab D, Al-Badriyeh D, Marquina C, Bailey C, Jaam M, Liew D, Ademi Z. A Systematic Review of Cost-Effectiveness of Non-Statin Lipid-Lowering Drugs for Primary and Secondary Prevention of Cardiovascular Disease in Patients with Type 2 Diabetes Mellitus. Curr Probl Cardiol 2022:101211. [PMID: 35460688 DOI: 10.1016/j.cpcardiol.2022.101211] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 12/24/2022]
Abstract
Although studies of non-statin lipid-lowering therapies (NSLLTs) have demonstrated cardiovascular benefits; whether these benefits provide good value has not been evaluated in type 2 diabetes mellitus (T2DM) patients. A systematic review was performed to include studies on the cost-effectiveness of NSLLTs in T2DM patients with/without cardiovascular disease (CVD). Thirteen studies were included; ezetimibe (n=8), proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (n=4), fenofibrate (n=2), nicotinic acid (n=1), extended-release niacin/laropiprant (ER- ERN/LRPT) (n=1), and icosapent ethyl (n=1). Six studies considered ezetimibe+statin to be a cost-effective compared to statins monotherapy, three studies suggested that PCSK9 inhibitors+statins were not cost-effective compared to statin+ezetimibe. Fenofibrate was a cost-effective either as monotherapy or combined with a statin compared to statin or fenofibrate monotherapy. Nicotinic acid and ER- ERN/LRPT compared to statin monotherapy were also cost-effective. Icosapent ethyl using the solid-state relay was cost-effective compared to standard care but not using the wholesale acquisition cost.
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Affiliation(s)
- Dina Abushanab
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Clara Marquina
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Cate Bailey
- University of Melbourne, Melbourne, Victoria, Australia
| | - Myriam Jaam
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Danny Liew
- The Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Zanfina Ademi
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia.
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Zhu Y, Hu H, Yang J, Yao Q, Xu H, Yu Y, Liu T, Lin S. The efficacy and safety of statin in combination with ezetimibe compared with double-dose statin in patients with high cardiovascular risk: A meta-analysis. Bosn J Basic Med Sci 2020; 20:169-182. [PMID: 31668143 PMCID: PMC7202188 DOI: 10.17305/bjbms.2019.4437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 10/06/2019] [Indexed: 12/21/2022] Open
Abstract
Currently, statins are the first-line therapies for dyslipidemia and atherosclerotic cardiovascular disease, however, their hypolipidemic effects have not been satisfactory. We performed a meta-analysis to compare lipid-lowering efficacy and safety of ezetimibe and statin combination therapy with double-dose statin monotherapy in patients with high cardiovascular risk. Fourteen studies involving 3105 participants were included in the final analysis; 1558 (50.18%) participants received ezetimibe and statin combination therapy and 1547 (49.82%) received double-dose statin monotherapy. Eight studies reported the percentages of changes in several lipid parameters from baseline to endpoint in both groups. Lipid parameters changed more significantly in patients coadministered with ezetimibe and statin (low-density lipoprotein cholesterol [LDL-C]: MD = -9.39, 95% CI -13.36 to -5.42; non-high-density lipoprotein cholesterol [non-HDL-C]: MD = -10.36, 95% CI -14.23 to -6.50; total cholesterol [TC]: MD = -8.11, 95% CI -10.95 to -5.26; and triglyceride [TG]: MD = -5.96, 95% CI -9.12 to -2.80), with moderate to high heterogeneity among the studies. Two out of fourteen studies investigated several different statins. Our subgroup analysis showed that, compared with double-dose atorvastatin monotherapy, ezetimibe and atorvastatin combination therapy significantly decreased LDL-C, non-HDL-C, TC, and TG levels by 14.16%, 14.01%, 11.06%, and 5.96%, respectively (p < 0.001). No significant difference was found in the incidence of laboratory-related adverse events (AEs) between statin combination therapy and monotherapy. Overall, ezetimibe and statin combination therapy significantly decreased LDL-C, non-HDL-C, and TC levels in patients with high cardiovascular risk, among which ezetimibe combined with atorvastatin had the best therapeutic effect. Compared with ezetimibe and statin combination therapy, double-dose statin monotherapy did not increase the risk of AEs.
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Affiliation(s)
- Yunyun Zhu
- Geriatrics Department, Ningbo First Hospital, Zhejiang, China
| | - Haochang Hu
- Cardiovascular Department, Ningbo First Hospital, Zhejiang, China. h
| | - Jun Yang
- Geriatrics Department, Ningbo First Hospital, Zhejiang, China
| | - Qi Yao
- Geriatrics Department, Ningbo First Hospital, Zhejiang, China
| | - Hongyu Xu
- Geriatrics Department, Ningbo First Hospital, Zhejiang, China
| | - Yushan Yu
- Geriatrics Department, Ningbo First Hospital, Zhejiang, China
| | - Ting Liu
- Geriatrics Department, Ningbo First Hospital, Zhejiang, China
| | - Shaoyi Lin
- Cardiovascular Department, Ningbo First Hospital, Zhejiang, China
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Suh DC, Griggs SK, Henderson ER, Lee SM, Park T. Comparative effectiveness of lipid-lowering treatments to reduce cardiovascular disease. Expert Rev Pharmacoecon Outcomes Res 2017; 18:51-69. [DOI: 10.1080/14737167.2018.1407246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Dong-Churl Suh
- Department of Pharmacy, Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Scott K. Griggs
- St Louis College of Pharmacy, Pharmacy Administration, St. Louis, MO, USA
- St. Louis College of Pharmacy, Center for Outcomes Research and Education, St. Louis, MO, USA
- Saint Louis University Center for Outcomes Research (SLUCOR), St. Louis, MO, USA
| | - Emmett R. Henderson
- Saint Louis University, Health Outcomes and Research and Evaluation Sciences, St. Louis, MO, USA
- Saint Louis University Center for Outcomes Research (SLUCOR), St. Louis, MO, USA
| | - Seung-Mi Lee
- Department of Pharmacy, Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Taehwan Park
- St Louis College of Pharmacy, Pharmacy Administration, St. Louis, MO, USA
- St. Louis College of Pharmacy, Center for Outcomes Research and Education, St. Louis, MO, USA
- Saint Louis University Center for Outcomes Research (SLUCOR), St. Louis, MO, USA
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Lee VW, Chau RY, Cheung HY, Yu CM, Lam YY, Yan BP. How low should we target the LDL goal to improve survival for acute coronary syndrome patients in Hong Kong? BMC Cardiovasc Disord 2015; 15:117. [PMID: 26446554 PMCID: PMC4597760 DOI: 10.1186/s12872-015-0117-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 09/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Utilization of lipid-lowering agents has been associated with improved long-term outcomes in acute coronary syndrome (ACS) patients. However, updated data regarding local use and outcomes was lacking. METHODS We retrospectively reviewed 696 hospitalized patients in the local ACS registry of Prince of Wales Hospital during 1 January 2008 to 31 December 2009 with data retrieved using computerized clinical records of all patients. RESULTS Among the 402 MI patients included, 104 (25.9 %) were not prescribed with statins at discharge. Percutaneous coronary intervention (PCI) not performed or planned during hospitalization (OR: 0.324, p = 0.001) and latest lower LDL-C level before discharge (OR: 0.221 for an increment of 1 mmol/L, p = 0.009) were significant independent predictors of the absence of statin prescriptions at discharge. A significantly lower all-cause mortality rate (14.4 % vs 51.7 %, p < 0.001), fewer total hospitalizations (p < 0.001) and fewer hospitalizations due to cardiovascular problems (p < 0.001) were observed in patients discharged with statins. LDL-C goal attainment of < 2.6 mmol/L resulted in a significant reduction in mortality (10.8 % vs 24.2 %, p = 0.001), but not for goal attainment of < 1.8 mmol/L. Significant difference in survival existed only when LDL-C cut-off values were above 2.4 mmol/L. CONCLUSIONS This study revealed the under-utilization of statin therapy in eligible MI patients at discharge and unsatisfactory percentages of LDL-C goal attainment, and also reassured the role of low LDL-C reduction to < 2.6 mmol/L in the management of MI. However, the current study did not show that the lower LDL-C reduction improved survival of ACS patients. Further research should be conducted to assess the necessity of aggressive LDL-C reduction to < 1.8 mmol/L in local patients.
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Affiliation(s)
- Vivian W Lee
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, 8th Floor, Lo Kwee-Seong Integrated Biomedical Sciences Building, Area 39, Shatin, Hong Kong.
| | - Raymond Y Chau
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, 8th Floor, Lo Kwee-Seong Integrated Biomedical Sciences Building, Area 39, Shatin, Hong Kong
| | - Herich Y Cheung
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, 8th Floor, Lo Kwee-Seong Integrated Biomedical Sciences Building, Area 39, Shatin, Hong Kong
| | - Cheuk Man Yu
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yat Yin Lam
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Bryan P Yan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
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Savarese G, Rosano GM, Parente A, D'Amore C, Reiner MF, Camici GG, Trimarco B, Perrone-Filardi P. Reduction of C-reactive protein is not associated with reduced cardiovascular risk and mortality in patients treated with statins. A meta-analysis of 22 randomized trials. Int J Cardiol 2014; 177:152-60. [DOI: 10.1016/j.ijcard.2014.09.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/30/2014] [Accepted: 09/16/2014] [Indexed: 12/26/2022]
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Ijioma N, Robinson JG. Lipid-lowering effects of ezetimibe and simvastatin in combination. Expert Rev Cardiovasc Ther 2014; 9:131-45. [DOI: 10.1586/erc.10.179] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Lew KN, Kent DJ, Muñoz AA, Melkus GD. Therapeutic options for lowering LDL-C in type 2 diabetes: a nurse practitioner's perspective. J Am Assoc Nurse Pract 2013; 25:488-94. [PMID: 24170653 DOI: 10.1002/2327-6924.12053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PURPOSE The majority of patients with type 2 diabetes mellitus (T2DM) have multiple risk factors for cardiovascular disease (CVD). Low-density lipoprotein cholesterol (LDL-C) is a key therapeutic target to reduce CVD risk. This article reviews therapeutic strategies that nurse practitioners (NPs) may use in the management of patients with T2DM requiring lipid management. DATA SOURCES The evidence used in developing this review included evidence-based reviews, clinical trials, guidelines, and consensus statements. Relevant publications were identified through a search of the literature using PubMed and other search engines. CONCLUSIONS Lowering LDL-C levels may reduce CVD risk, but achieving goals can be challenging. Lifestyle modifications (including diet, exercise, and smoking cessation) are key components of lipid management and reduction of CVD risk. Statins can be effective to reduce lipids. However, patients may not achieve lipid goals with monotherapy or may experience intolerable adverse effects. Alternative statins or statins along with other lipid-lowering agents remain good options. IMPLICATIONS FOR PRACTICE Achieving LDL-C goals requires a comprehensive treatment plan that incorporates lifestyle and pharmacologic interventions. Patient commitment in setting goals and self-management is essential. NPs can play an important role in educating patients as well as prescribing appropriate treatments.
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van Nooten F, Davies GM, Jukema JW, Liem AH, Yap E, Hu XH. Economic evaluation of ezetimibe combined with simvastatin for the treatment of primary hypercholesterolaemia. Neth Heart J 2013; 19:61-7. [PMID: 22020943 DOI: 10.1007/s12471-010-0061-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This study aims to assess the cost-effectiveness of ezetimibe plus simvastatin (E/S) versus atorvastatin or simvastatin monotherapy as second-line treatment of primary hypercholesterolaemia from the Dutch healthcare perspective. METHODS The evaluation used a Markov model and patient data from the Dutch EASEGO study in which patients failing to reach goal low-density lipoprotein cholesterol levels on atorvastatin 10 mg or simvastatin 20 mg had their dose doubled or switched to ezetimibe 10 mg plus generic simvastatin 20 mg (E10/S20). The second scenario, based on Dutch guidelines, switched patients from simvastatin 40 mg to atorvastatin 40 mg, or ezetimibe 10 mg was added to simvastatin 40 mg (E10/S40). The key effectiveness input measure was change in total cholesterol/high-density lipoprotein ratio obtained from the EASEGO study. In conformity with published studies linking reduced lipid levels to reduced risk of cardiovascular events, the present model assumed that a lipid decrease with ezetimibe may be a signal for reduced risk of cardiovascular events. Model parameters were derived from published literature. Sensitivity analyses were performed for the key parameters. RESULTS In the EASEGO scenario, incremental cost-effectiveness ratio for E10/S20 was <euro>3497/quality-adjusted life-years (QALY) vs atorvastatin 20 mg and <euro>26,417/QALY vs simvastatin 40 mg. In the Dutch guidelines scenario, E10/S40 was dominant (more effective and cost-saving) vs atorvastatin 40 mg. Varying model inputs had limited impact on the cost-effectiveness of E/S. CONCLUSIONS The analysis showed the cost-effectiveness of E/S versus atorvastatin 20 mg or simvastatin 40 mg (EASEGO scenario) at a threshold of <euro>30,000/QALY and vs atorvastatin 40 mg was dominant (Dutch guidelines). Thus, E/S seems a valuable cost-effective second-line treatment option for patients not attaining lipid treatment goals.
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Affiliation(s)
- F van Nooten
- United BioSource Corporation, 26-28 Hammersmith Grove, London, W6 7HA, UK,
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10
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Catapano A, Toth PP, Tomassini JE, Tershakovec AM. The efficacy and safety of ezetimibe coadministered with statin therapy in various patient groups. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/clp.12.88] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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11
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The comparative efficacy of ezetimibe added to atorvastatin 10 mg versus uptitration to atorvastatin 40 mg in subgroups of patients aged 65 to 74 years or greater than or equal to 75 years. J Geriatr Cardiol 2012; 8:1-11. [PMID: 22783278 PMCID: PMC3390058 DOI: 10.3724/sp.j.1263.2011.00001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 03/17/2011] [Accepted: 03/24/2011] [Indexed: 12/02/2022] Open
Abstract
Background Coronary heart disease (CHD) risk increases with age; yet lipid-lowering therapies are significantly under-utilized in patients > 65 years. The objective was to evaluate the safety and efficacy of lipid-lowering therapies in older patients treated with atorvastatin 10 mg + ezetimibe 10 mg (EZ/Atorva) vs. increasing the atorvastatin dose to 40 mg. Methods Patients ≥ 65 years with atherosclerotic vascular disease (LDL-C ≥ 1.81 mmol/L) or at high risk for coronary heart disease (LDL-C ≥ 2.59 mmol/L) were randomized to EZ/Atorva for 12 wk vs. uptitration to atorvastatin 20 mg for 6 wk followed by atorvastatin 40 mg for 6 wk. The percent change in LDL-C and other lipid parameters and percent patients achieving prespecified LDL-C levels were assessed after 12 wk. Results EZ/Atorva produced greater reductions in most lipid parameters vs. uptitration of atorvastatin in patients ≥ 75 years (n = 228), generally consistent with patients 65–74 years (n = 812). More patients achieved LDL-C targets with combination therapy vs. monotherapy in both age groups at 6 wk and in patients ≥ 75 years at 12 wk. At 12 wk, more patients ≥ 75 years achieved LDL-C targets with monotherapy vs. combination therapy. EZ/Atorva produced more favorable improvements in most lipids vs. doubling or quadrupling the atorvastatin dose in patients ≥ 75 years, generally consistent with the findings in patients 65–74 years. Conclusions Our results extended previous findings demonstrating that ezetimibe added to a statin provided a generally well-tolerated therapeutic option for improving the lipid profile in patients 65 to 74 years and ≥ 75 years of age.
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Davis HR, Tershakovec AM, Tomassini JE, Musliner T. Intestinal sterol transporters and cholesterol absorption inhibition. Curr Opin Lipidol 2011; 22:467-78. [PMID: 22101558 DOI: 10.1097/mol.0b013e32834c7c28] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Statin therapy is the mainstay of lipid-lowering therapy; however, many patients, particularly those at high risk, do not achieve sufficient LDL-cholesterol (LDL-C) lowering. Thus, there remains an unmet medical need for more effective and well tolerated lipid-lowering agents. Guidelines recommend combining additional lipid-lowering agents with a complementary mode of action for these patients. One approach to complementing statin therapy is combination with inhibitors that block the intestinal absorption of dietary and biliary cholesterol. This review summarizes what is currently known about intestinal sterol transporters and cholesterol absorption inhibitors (CAIs). RECENT FINDINGS The only lipid-lowering agent currently available that specifically targets an intestinal sterol transporter (Niemann-Pick C1-like 1) is the CAI, ezetimibe. It is effective in lowering LDL-C, both when given alone and when combined with a statin. Clinical outcome data with ezetimibe combined with simvastatin have recently become available, and definitive evidence that the incremental LDL-C lowering attributable to the ezetimibe component reduces cardiovascular events beyond simvastatin alone is currently under study. Other novel CAIs have been evaluated based upon the structure and properties of ezetimibe, but none remain in development. SUMMARY Additional lipid-lowering agents are needed to fulfill an unmet medical need for those patients who do not achieve optimal LDL-C goals on statin monotherapy. The inhibition of cholesterol absorption is an important therapeutic strategy to reduce cholesterol levels. Based upon the demonstrated lipid-altering efficacy and safety of ezetimibe, several CAIs have been identified; all to date have been discontinued due to limited efficacy.
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Affiliation(s)
- Harry R Davis
- Merck Research Laboratories, Merck Sharp & Dohme Corp./Merck & Co., Inc., Whitehouse Station, New Jersey, USA.
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Abramson BL, Benlian P, Hanson ME, Lin J, Shah A, Tershakovec AM. Response by sex to statin plus ezetimibe or statin monotherapy: a pooled analysis of 22,231 hyperlipidemic patients. Lipids Health Dis 2011; 10:146. [PMID: 21859459 PMCID: PMC3180404 DOI: 10.1186/1476-511x-10-146] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 08/22/2011] [Indexed: 01/14/2023] Open
Abstract
Background Despite documented benefits of lipid-lowering treatment in women, a considerable number are undertreated, and fewer achieve treatment targets vs. men. Methods Data were combined from 27 double-blind, active or placebo-controlled studies that randomized adult hypercholesterolemic patients to statin or statin+ezetimibe. Consistency of treatment effect among men (n = 11,295) and women (n = 10,499) was assessed and percent of men and women was calculated to evaluate the between-treatment ability to achieve specified treatment levels between sexes. Results Baseline lipids and hs-CRP were generally higher in women vs. men. Between-treatment differences were significant for both sexes (all p < 0.001 except apolipoprotein A-I in men = 0.0389). Men treated with ezetimibe+statin experienced significantly greater changes in LDL-C (p = 0.0066), non-HDL-C, total cholesterol, triglycerides, HDL-C, apolipoprotein A-I (all p < 0.0001) and apolipoprotein B (p = 0.0055) compared with women treated with ezetimibe+statin. The odds of achieving LDL-C < 100 mg/dL, apolipoprotein B < 90 mg/dL and the dual target [LDL-C < 100 mg/dL & apoliprotein B < 90 mg/dL] was significantly greater for women vs. men and the odds of achieving hs-CRP < 1 and < 2 mg/L and dual specified levels of [LDL-C < 100 mg/dL and hs-CRP < 2 mg/L] were significantly greater for men vs. women. Women reported significantly more gall-bladder-related, gastrointestinal-related, and allergic reaction or rash-related adverse events (AEs) vs. men (no differences between treatments). Men reported significantly more CK elevations (no differences between treatments) and hepatitis-related AEs vs. women (significantly more with ezetimibe+simvastatin vs. statin). Conclusions These results suggest that small sex-related differences may exist in response to lipid-lowering treatment and achievement of specified lipid and hs-CRP levels, which may have implications when managing hypercholesterolemia in women.
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Mikhailidis DP, Lawson RW, McCormick AL, Sibbring GC, Tershakovec AM, Davies GM, Tunceli K. Comparative efficacy of the addition of ezetimibe to statin vs statin titration in patients with hypercholesterolaemia: systematic review and meta-analysis. Curr Med Res Opin 2011; 27:1191-210. [PMID: 21473671 DOI: 10.1185/03007995.2011.571239] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To systematically review and analyse evidence for cholesterol-lowering efficacy of at least 4 weeks of add-on ezetimibe vs doubling statin dose, in adults with primary hypercholesterolaemia. RESEARCH DESIGN AND METHODS MEDLINE, EMBASE and Cochrane databases were searched to identify randomised controlled trials of ezetimibe-statin combination vs statin titration (January 1993 - March 2010). Studies were selected using predefined criteria. Two reviewers conducted screening of articles, critical appraisal and data extraction; a third reviewer resolved disagreements. The difference between treatments was analysed for four co-primary outcomes: mean percentage change from baseline in low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and total cholesterol (TC); and proportion of patients achieving LDL-C treatment goal. Data were combined by two sets of direct comparison fixed and random effects meta-analysis: (1) compared data in the same treatment period between groups; (2) compared the incremental change in lipid levels of add-on ezetimibe vs doubling statin dose. Heterogeneity was assessed using the I(2) statistic. RESULTS Thirteen studies including 5080 patients were included in the meta-analyses. Data on simvastatin, atorvastatin and rosuvastatin were analysed. Results for primary and secondary outcomes were in favour of the ezetimibe-statin combination. A significantly greater percentage reduction in LDL-C levels was achieved in patients treated with ezetimibe-statin vs statin monotherapy (weighted mean difference [WMD]: -14.1% [-16.1, -12.1], p < 0.001). Reduction in LDL-C levels attributed to add-on ezetimibe was significantly greater than that for statin dose doubling (WMD: -15.3% [-19.1, -11.4], p < 0.001). Achievement of LDL-C goal favoured add-on ezetimibe over statin titration and was statistically significant (odds ratio: LDL-C treatment goal 2.45 [1.95, 3.08], p = 0.007). CONCLUSIONS Meta-analyses were restricted by the limited number of studies with similar trial design and method of statin titration. Results indicate that add-on ezetimibe is significantly more effective in reducing LDL-C levels than doubling statin dose, enabling more patients to achieve LDL-C goal.
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Affiliation(s)
- Dimitri P Mikhailidis
- Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), University College London (UCL) Medical School, London, UK.
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Jacobson TA. 'Trig-onometry': non-high-density lipoprotein cholesterol as a therapeutic target in dyslipidaemia. Int J Clin Pract 2011; 65:82-101. [PMID: 21105969 DOI: 10.1111/j.1742-1241.2010.02547.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Targeting elevations in low-density lipoprotein cholesterol (LDL-C) remains the cornerstone of cardiovascular prevention. However, this fraction does not adequately capture elevated triglyceride-rich lipoproteins (TRLs; e.g. intermediate-density lipoprotein, very low density lipoprotein) in certain patients with metabolic syndrome or diabetic dyslipidaemia. Many such individuals have residual cardiovascular risk that might be lipid/lipoprotein related despite therapy with first-line agents (statins). Epidemiological evidence encompassing > 100,000 persons supports the contention that non-high-density lipoprotein cholesterol (non-HDL-C) is a superior risk factor vs. LDL-C for incident coronary heart disease (CHD) in certain patient populations. In studies with clinical end-points evaluated in the current article, a 1:1 to 1:3 relationship was observed between reductions in non-HDL-C and in the relative risk of CHD after long-term treatment with statins, niacin (nicotinic acid) and fibric-acid derivatives (fibrates); this relationship increased to 1:5 to 1:10 in smaller subgroups of patients with elevated triglycerides and low HDL-C levels. Treatment with statin-, niacin-, fibrate-, ezetimibe-, and omega 3 fatty acid-containing regimens reduced non-HDL-C by approximately 9-65%. In a range of clinical trials, long-term treatment with these agents also significantly decreased the incidence of clinical/angiographic/imaging efficacy outcome variables. For patients with dyslipidaemia, consensus guidelines have established non-HDL-C treatment targets 30 mg/dl higher than LDL-C goals. Ongoing prospective randomised controlled trials should help to resolve controversies concerning (i) the clinical utility of targeting non-HDL-C in patients with dyslipidaemia; (ii) the most efficacious and well-tolerated therapies to reduce non-HDL-C (e.g. combination regimens); and (iii) associations between such reductions and clinical, angiographic, and/or imaging end-points.
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Affiliation(s)
- T A Jacobson
- Office of Health Promotion and Disease Prevention, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, USA.
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Toth PP, Catapano A, Tomassini JE, Tershakovec AM. Update on the efficacy and safety of combination ezetimibe plus statin therapy. ACTA ACUST UNITED AC 2010. [DOI: 10.2217/clp.10.49] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Reckless J, Davies G, Tunceli K, Hu XH, Brudi P. Projected cost-effectiveness of ezetimibe/simvastatin compared with doubling the statin dose in the United Kingdom: findings from the INFORCE study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2010; 13:726-734. [PMID: 20561328 DOI: 10.1111/j.1524-4733.2010.00742.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To evaluate the incremental cost-effectiveness ratio (ICER) of switching to ezetimibe/simvastatin (Eze/Simva) compared with doubling the submaximal statin doses, in patients with acute coronary syndrome (ACS) events in the INFORCE study. METHODS Lifetime treatment costs and benefits were computed using a Markov model. Model inputs included each patient's cardiovascular risk factor profile and actual lipid values at baseline and 12 weeks (endpoint). Cardiovascular event and drug costs were discounted at 3.5%. Age-specific utilities were based on UK literature values and non-coronary heart disease mortality rates on the Office of National Statistics data. In the INFORCE study, 384 patients taking statins at stable doses for ≥6 weeks before hospital admission were stratified by statin dose/potency (low, medium, and high) and then randomized to doubling the statin dose or switching to Eze/Simva 10/40mg for 12 weeks. RESULTS The Eze/Simva group (n=195) had a higher mean baseline total cholesterol than the double-statin group (n=189). Analyses were adjusted for baseline characteristics. In the INFORCE study, Eze/Simva reduced low-density lipoprotein cholesterol (LDL-C) by ∼30% (vs. 4% with doubling statin doses) and significantly enhanced LDL-C goal attainment. In the cost-effectiveness analysis, Eze/Simva conferred 0.218 incremental discounted quality-adjusted life year (QALY) at a discounted incremental cost of £2524, for an ICER of £11,571/QALY (95% confidence interval=£8181-£18,600/QALY). The ICER was £13,552/QALY, £11,930/QALY, and £10,148/QALY in the low-, medium-, and high-potency strata, respectively. CONCLUSIONS Switching to Eze/Simva 10/40 mg is projected to be a cost-effective treatment (vs. double-statin) in UK patients with ACS.
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Affiliation(s)
- John Reckless
- Royal United Hospital, Bath, and Honorary Reader in Medicine, University of Bath, Bath, UK
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Willey VJ, Reinhold JA, Willey KH, Kelly BL, Cziraky MJ. Clinical and economic outcomes in patients switched to simvastatin in a community-based family medicine practice. Int J Clin Pract 2010; 64:1235-8. [PMID: 20653799 DOI: 10.1111/j.1742-1241.2010.02423.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The introduction of a generic formulation of simvastatin has created the potential to provide significant low-density lipoprotein cholesterol (LDL-C) reduction in a highly cost-effective manner. METHODS This retrospective cohort analysis utilised electronic medical record data from a United States, community-based, independent physician family medicine practice. Patients switched from other statins or statin combinations to simvastatin by the family medicine physicians during routine patient care from January 2002 to October 2008 were identified. Equivalent statin dosing, lipid panel changes and National Cholesterol Education Program--Adult Treatment Panel III (NCEP) LDL-C goal attainment rates were compared preswitch and postswitch. The potential economic impact of simvastatin switching was also evaluated. RESULTS A total of 78 patients were identified, and in 76.9% of the switches, an equipotent dose of simvastatin was prescribed. All lipid fractions showed small, non-significant increases, with LDL-C having a 2.2 mg/dl (0.06 mmol/l) increase after switching (p = 0.476). NCEP LDL-C goal attainment rates were 79.5% and 78.2% before and after switching, respectively (p = 1.00). Modelled annual cost savings associated with switching were estimated at $671.99 per patient. CONCLUSIONS These results demonstrate that an independent family medicine physician practice can successfully perform statin therapeutic substitution during routine patient care. Equivalent clinical outcomes with regards to changes in lipid fractions and NCEP LDL-C goal attainment were observed in conjunction with the potential for reduced costs for patients.
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Affiliation(s)
- V J Willey
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA 19104, USA.
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McCormack T, Harvey P, Gaunt R, Allgar V, Chipperfield R, Robinson P. Incremental cholesterol reduction with ezetimibe/simvastatin, atorvastatin and rosuvastatin in UK General Practice (IN-PRACTICE): randomised controlled trial of achievement of Joint British Societies (JBS-2) cholesterol targets. Int J Clin Pract 2010; 64:1052-61. [PMID: 20487050 DOI: 10.1111/j.1742-1241.2010.02429.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIM The aim of this study was to compare ezetimibe/simvastatin combination therapy with intensified statin monotherapy as alternative treatment strategies to achieve the Joint British Societies (JBS)-2 and National Institute for Health and Clinical Excellence low-density-lipoprotein cholesterol (LDL-C) target of < 2 mmol/l for secondary prevention or JBS-2 LDL-C target of < 2 mmol/l for primary prevention in high-risk patients who have failed to reach target with simvastatin 40 mg. METHODS This is a prospective, double-blind study conducted in 34 UK primary care centres; 1748 patients with established cardiovascular disease (CVD), diabetes or high risk of CVD who had been taking simvastatin 40 mg for > or = 6 weeks were screened and 786 (45%) with fasting LDL-C > or = 2.0 mmol/l (and < 4.2 mmol/l) at screening and after a further 6-week run-in period on simvastatin 40 mg were randomised to ezetimibe/simvastatin 10/40 mg (as a combination tablet; n = 261), atorvastatin 40 mg (n = 263) or rosuvastatin 5 mg (n = 73) or 10 mg (n = 189) once daily for 6 weeks. Rosuvastatin dose was based on UK prescribing instructions. The primary outcome measure was the proportion of patients achieving LDL-C < 2 mmol/l at the end of the study. RESULTS The percentage of patients (adjusted for baseline differences) achieving LDL-C < 2 mmol/l was 69.4% with ezetimibe/simvastatin 10/40 mg, compared with 33.5% for atorvastatin 40 mg [odds ratio 4.5 (95% CI: 3.0-6.8); p < 0.001] and 14.3% for rosuvastatin 5 or 10 mg [odds ratio 13.6 (95% CI: 8.6-21.6); p < 0.001]. Similar results were observed for achievement of total cholesterol < 4.0 mmol/l. All study treatments were well tolerated. CONCLUSION Approximately 45% of patients screened had not achieved LDL-C < 2 mmol/l after > or = 12 weeks of treatment with simvastatin 40 mg. In this group, treatment with ezetimibe/simvastatin 10/40 mg achieved target LDL-C levels in a significantly higher proportion of patients during a 6-week period than switching to either atorvastatin 40 mg or rosuvastatin 5-10 mg.
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Affiliation(s)
- T McCormack
- Whitby Group Practice, Spring Vale Medical Centre, Whitby, UK.
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21
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Zielwerterreichung unter lipidsenkender Therapie mit Ezetimib/Simvastatin bei Patienten mit Atherosklerose und/oder Diabetes mellitus – eine österreichische Anwendungsbeobachtung. Wien Med Wochenschr 2009; 159:558-64. [DOI: 10.1007/s10354-009-0723-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Farnier M, Averna M, Missault L, Vaverkova H, Viigimaa M, Massaad R, Vandormael K, Johnson-Levonas AO, Brudi P. Lipid-altering efficacy of ezetimibe/simvastatin 10/20 mg compared with rosuvastatin 10 mg in high-risk hypercholesterolaemic patients inadequately controlled with prior statin monotherapy - The IN-CROSS study. Int J Clin Pract 2009; 63:547-59. [PMID: 19222610 DOI: 10.1111/j.1742-1241.2009.02022.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIMS To evaluate the efficacy of switching from a previous statin monotherapy to ezetimibe/simvastatin (EZE/SIMVA) 10/20 mg vs. rosuvastatin (ROSUVA) 10 mg. METHODS In this randomised, double-blind study, 618 patients with documented hypercholesterolaemia [low-density lipoprotein cholesterol (LDL-C) > or = 2.59 and < or = 4.92 mmol/l] and with high cardiovascular risk who were taking a stable daily dose of one of several statin medications for > or = 6 weeks prior to the study randomisation visit entered a 6-week open-label stabilisation/screening period during which they continued to receive their prestudy statin dose. Following stratification by study site and statin dose/potency, patients were randomised to EZE/SIMVA 10/20 mg (n = 314) or ROSUVA 10 mg (n = 304) for 6 weeks. RESULTS EZE/SIMVA produced greater reductions in LDL-C (-27.7% vs. -16.9%; p < or = 0.001), total cholesterol (-17.5% vs. -10.3%; p < or = 0.001), non-high-density lipoprotein cholesterol (HDL-C) (-23.4% vs. -14.0%; p < or = 0.001) and apolipoprotein B (-17.9% vs. -9.8%; p < or = 0.001) compared with ROSUVA, while both treatments were equally effective at increasing HDL-C (2.1% vs. 3.0%; p = 0.433). More patients achieved LDL-C levels < 2.59 mmol/l (73% vs. 56%), < 2.00 mmol/l (38% vs. 19%) and < 1.81 mmol/l (25% vs. 11%) with EZE/SIMVA than ROSUVA (p < or = 0.001). A borderline significantly greater reduction in triglycerides (p = 0.056) was observed for EZE/SIMVA (-11.0%) vs. ROSUVA (-5.3%). There were no between-group differences in the incidences of adverse events or liver transaminase and creatine kinase elevations. CONCLUSION EZE/SIMVA 10/20 mg produced greater improvements in LDL-C, total cholesterol, non-HDL-C and apoB with a similar safety profile as for ROSUVA 10 mg.
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Affiliation(s)
- M Farnier
- Point Medical, Rond Point de Nation, Dijon, France.
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Current Opinion in Endocrinology, Diabetes & Obesity. Current world literature. Curr Opin Endocrinol Diabetes Obes 2009; 16:189-202. [PMID: 19300094 DOI: 10.1097/med.0b013e328329fcc2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Elevated levels of low-density lipoprotein cholesterol (LDL-C) are associated with an increased risk of coronary heart disease (CHD). European and US guidelines now recommend lower LDL-C levels, particularly in high-risk patients. Although LDL-C treatment goals to reduce the risk of CHD are clear, many patients do not reach their LDL-C goals. OBJECTIVES Examine consensus guideline targets for LDL-C lowering in patients at high or very high cardiovascular risk; examine cholesterol goal achievement in clinical practice; evaluate the effectiveness of ezetimibe/statin and other adjunctive lipid-lowering treatments in achieving LDL-C goals; and consider ongoing controversies and the randomized controlled trials that may help to resolve or better illuminate them. METHODS An English-language PubMed search was conducted to identify prospective randomized controlled trials, open-label studies, and retrospective and observational studies from 2001 (same year that the executive summary of the National Cholesterol Education Program's Adult Treatment Panel III was published) to present for an analysis of the effects of adjunctive therapies on LDL-C lowering and goal attainment in patients at elevated cardiovascular risk. RESULTS Elevated LDL-C is the primary target of lipid-lowering therapy; aggressive lowering is of great benefit to those at high risk. Statins are recommended first-line lipid-lowering agents, with a long, well-regarded history of efficacy and safety. Not all patients, however, can achieve recommended LDL-C goals simply using starting doses of statins. For such patients, more intensive therapy utilizing high-dose statins or combination therapy, including statins combined with other lipid-lowering agents, such as ezetimibe, bile acid resins (BARs), or niacin, is warranted. Potential limitations of the present review include possible publication bias and the focus on pharmacotherapy rather than lifestyle modification and the important objective of multiple risk-factor modification to reduce absolute global cardiovascular risk. CONCLUSIONS With a well-established link between elevated LDL-C and cardiovascular risk, aggressive LDL-C lowering becomes particularly important. Patients needing intensive LDL-C lowering to achieve goals will often require adjunctive treatments, including ezetimibe, BARs, or niacin along with statins. Given both their high mg: mg potency in lowering LDL-C and favorable tolerability and patient acceptance/adherence profile, ezetimibe/statin combination regimens arguably provide the greatest likelihood for patients to reach new, lower LDL-C targets; however, efficacy and safety data of any adjunctive treatment, along with drug costs and patient adherence to treatment (partly related to complexity of the regimen) all need to be considered when determining the optimal regimen to achieve LDL-C goals in individual patients according to their baseline absolute cardiovascular risk, LDL-C level, and consensus LDL-C targets.
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Affiliation(s)
- Alberico L Catapano
- Marie Curie Training Centre for Cardiovascular Diseases, University of Milan, Milan, Italy.
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