Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach

Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach Conducted during the 41 st ASHP Midyear Clinical Meeting Anaheim, California

CONTINUING EDUCATION ACCREDITATION The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This program provides 1 hour (0.1 CEU) of continuing education credit (program number 204-000-06-439-H01). After successful completion of the CE post test, participants can print the CE statement online at www.ashpadvantage.com.

Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach PROGRAM AGENDA Introductory Remarks Joseph Saseen, Pharm.D., BCPS, FCCP, Program Moderator Overview of Atherogenesis and Goals of Pharmacotherapy Barbara S. Wiggins, Pharm.D., BCPS Case Studies in the Management of Dyslipidemia: Understanding Statin Myopathy and Avoiding Clinical Inertia Joseph Saseen, Pharm.D., BCPS, FCCP PROGRAM FACULTY Joseph Saseen, Pharm.D., BCPS, FCCP (AQ Cardiology) Associate Professor Departments of Clinical Pharmacy and Family Medicine University of Colorado Health Sciences Center Denver, Colorado Barbara S. Wiggins, Pharm.D., BCPS (AQ Cardiology) Pharmacy Clinical Specialist Cardiology University of Virginia Health System Clinical Assistant Professor in Internal Medicine University of Virginia School of Medicine Charlottesville, Virginia

Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach PROGRAM DESCRIPTION Cardiovascular disease is the number one killer of both men and women in the United States, and the disease has an enormous economic impact. Dyslipidemia is a major risk factor for cardiovascular disease. Epidemiologic data have demonstrated a correlation between lowdensity lipoprotein (LDL) cholesterol and the risk for coronary heart disease (CHD). Therefore, LDL cholesterol is the primary target of therapeutic interventions for patients with dyslipidemia. Other lipids, lipoproteins, and CHD risk factors are secondary targets. HMG-CoA reductase inhibitors, otherwise known as statins, are the agents of choice for lowering LDL cholesterol. Statins are also effective in lowering the risk of cardiovascular events. Intensive lipid-lowering therapy utilizing high-dose statins has been shown to provide greater clinical benefit than moderate-dose statin therapy for reduction of cardiovascular events in those patients at very high risk. Some patients with dyslipidemia fail to achieve a target LDL-cholesterol goal despite pharmacotherapy with maximum recommended statin doses. Failure to achieve adequate LDL reduction can be costly and the use of combination drug therapy may be necessary to help patients achieve therapeutic goals. Some patients may also experience statin-associated side effects such as myopathy. Although these muscle-related side effects often decrease patient compliance, they do not always represent a serious adverse drug event. This program will describe the rationale for targeting LDL cholesterol in patients with dyslipidemia. Three case studies will be used to illustrate the therapeutic decision-making process based on the results of current clinical trials and scientific evidence. Patient cases will be varied to illustrate evidence-based options available to pharmacists who manage drug therapy in this population. An interactive question-and-answer discussion will be held at the conclusion of the program. LEARNING OBJECTIVES At the conclusion of this presentation, participants should be able to: Characterize the relationship between LDL cholesterol and the risk for CHD, and identify the primary target and a secondary target for therapeutic intervention to reduce CHD risk in patients with dyslipidemia. Assess the lipid profile and other CHD risk factors in a patient hospitalized for acute coronary syndrome, and recommend non-drug as well as drug therapy to manage dyslipidemia. Evaluate the response to lipid-lowering drug therapy in a patient experiencing muscle pain and revise the therapeutic plan if the response is inadequate. Discuss the rationale and recommendation for managing a patient with diabetes and uncontrolled dyslipidemia. Identify common barriers to achieving therapeutic goals in patients with dyslipidemia and strategies for overcoming these barriers.

Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach Case 1 MG is a 75-yr-old male with DM, and no significant CAD Hx, who presents to the ER with a CC of chest pain. Patient is diagnosed with a STEMI and undergoes cardiac catheterization. He was on no medications prior to admission. His fasting lipid panel revealed the following: Fasting Labs: TC = 188 mg/dl, HDL-C = 39 mg/dl LDL-C = 123 mg/dl, TGs = 157 mg/dl Patient does not smoke or drink. Medications on discharge: Aspirin 325 mg daily, clopidogrel 75 mg daily, metoprolol 50 mg twice daily, lisinopril 10 mg daily and atorvastatin 80 mg daily. MG now presents to clinic 4 weeks following hospital discharge and pertinent laboratory results are as follows: AST = 110 ALT = 123 ALK Phos = 450 Reflective Questions What is this patient s LDL goal? What percentage reduction in LDL is needed? Is atorvastatin at 80 mg appropriate in this patient? Should the atorvastatin be discontinued? What medication changes if any should occur?

Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach Case 2 GG is a 56-yr-old man with a past medical history of hypertension and dyslipidemia. Smokes, is obese (waist circumference is 45, BMI is 32 kg/m2), and Framingham Risk score is 18% Medications: Simvastatin 40 mg daily at bedtime, aspirin 81 mg daily, lisinopril 10 mg daily, hydrochlorothiazide 25 mg daily Fasting Labs: TC = 180 mg/dl, HDL-C = 39 mg/dl, LDL-C = 95 mg/dl, TGs = 180 mg/dl glucose 110 mg/dl all other labs, including a TSH are within normal limits GG has recently read information from the internet about muscle-related statin side effects. He has had muscle soreness for many years now, but did not think it was a problem. He reported this to his physician, who then measured his creatine kinase; it was 400 IU/L (normal: 0-200). GG is now concerned about continuing his statin. Reflective Questions What are his goals of therapy, and what is the benefit of statin therapy? Fear of myopathy is a barrier to treatment. Does simvastatin have to be stopped because of his muscle symptoms? What medication changes should be implemented?

Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach Case 3 RP is a 65-yr-old woman on atorvastatin 10 mg daily. Past medical history: type 2 diabetes, hypertension, dyslipidemia, and an ischemic stroke. Medications: Atorvastatin 10 mg daily, aspirin 81 mg daily, losartan 100 mg daily, hydrochlorothiazide 25 mg daily, metformin 1000 mg twice daily, insulin glargine 30 U daily in the evening Fasting Labs: TC = 185 mg/dl, HDL-C = 45 mg/dl, LDL-C = 90 mg/dl, TGs = 250 mg/dl A1C is 6.8 mg/dl (target < 7 mg/dl for diabetes) all other labs, within normal limits Reflective Questions What are her goals of therapy? Is single drug therapy as effective as combination drug therapy? Clinical Inertia is a barrier to treatment. What is the evidence supporting treatment of this type of patient?

Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach BARBARA S. WIGGINS, PHARM.D., BCPS (AQ CARDIOLOGY) Pharmacy Clinical Specialist Cardiology University of Virginia Health System Clinical Assistant Professor in Internal Medicine University of Virginia School of Medicine Charlottesville, Virginia Barbara S. Wiggins, Pharm.D., BCPS, is Clinical Assistant Professor in Internal Medicine at the University of Virginia School of Medicine, Clinical Instructor for the University of Virginia School of Nursing, and Pharmacy Clinical Specialist in Cardiology at the University of Virginia Health System Heart Center in Charlottesville, Virginia. Dr. Wiggins also holds an adjunct faculty appointment of Clinical Assistant Professor at Virginia Commonwealth University/Medical College of Virginia School of Pharmacy in Richmond, Virginia. In 1996, Dr. Wiggins received her Doctor of Pharmacy degree from Virginia Commonwealth University/Medical College of Virginia in Richmond, Virginia, after which she completed a fellowship in Cardiology and Emergency Medicine. Some of Dr. Wiggins accomplishments include: Junior Alumni of the Year Award from St. Louis College of Pharmacy, Rho Chi Pharmacy Honor Society, Merck Award for Clinical Research, and board certification in pharmacotherapy with added qualifications in cardiology. Dr. Wiggins has published two book chapters and authored numerous articles in the fields of cardiology and emergency medicine. Dr. Wiggins is currently co-authoring a book entitled A Pharmacists Guide to Lipid Management.

Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach 41st ASHP Midyear Clinical Meeting Anaheim ~ Orange County, California Overview of Atherogenesis and Goals of Pharmacotherapy Barbara S. Wiggins, Pharm.D., BCPS (AQ Cardiology) Pharmacy Clinical Specialist University of Virginia Health System Charlottesville, Virginia Pathogenesis of Atherosclerosis Atherosclerosis Diffuse disease of medium and larger arteries Progressive disease Age 15 Age 40 Age 65

Pathogenesis of Atherosclerosis Intrinsic cells Endothelium Smooth muscle Cells Inflammatory Cells Mast Cells T-Lymphocytes Macrophages Mechanisms of Atherosclerosis Macrophage T-lymphocytes Smooth Muscle Cells

Optical Coherence Tomogram of a Vulnerable Plaque Role of Lipid-Lowering Therapy Changes composition especially in vulnerable plaques Stabilizing plaques Reduces progression Partial regression

Risk Factors Low HDL < 35 mg/dl Hypertension Smoking Diabetes Age Family History NCEP ATP III: 2004 Report Risk Category High Risk * CHD or equivalents (10-yr risk > 20%) Moderately High Risk * 2+ risk factors (10-yr risk 10 to 20%) Moderate Risk 2+ risk factors (10-yr risk < 10%) Lower Risk 0 to 1 risk factors LDL-C goal (mg/dl) < 100 (Optional <70) # < 130 (Optional < 100) < 130 < 160 # Very high risk favors < 70 mg/dl * High risk or moderately high with lifestyle-related risk should be on therapeutic lifestyle changes regardless of LDL-C, and should achieve at least a 30 to 40% LDL-C reduction 10-yr risk of CHD based on Framingham Scoring Circulation 2004; 110:227-239. Magnitude of the Disease Number of killer of men and women in the U.S. Present in 13.2 million. Accounts for 37.3% of all adult deaths. Claims an average of 1 life every 35 seconds. AHA Heart Disease and Stroke Statistics 2006.

Population (%) 100 90 80 70 60 50 40 30 20 10 0 11.2 6.2 CVD in the US Men 22.9 17.6 Women 36.2 36.6 52.9 56.5 20-34 35-44 45-54 55-64 65-74 75+ Age (Years) 86.4 68.5 75.0 77.8 AHA 2005 Statistics Update Case Study #1: Management of Statininduced Transaminase Elevations MG is a 75-yr-old male with DM, and no significant CAD Hx who presents to the ER with a CC of chest pain. Pt. is diagnosed with a STEMI and undergoes cardiac cath. His fasting lipid panel revealed the following: TC = 188 mg/dl, HDL-C = 39 LDL-C = 123, TGs = 157 The patient is started on atorvastatin 80 mg Case #1 Cont: The patient presents to clinic 1 month following hospital discharge and pertinent lab results are as follows: AST = 110 ALT = 123 ALK Phos = 450

Case #1 Cont. What is this patient s LDL Goal? What percent reduction in LDL is needed? Is atorvastatin at 80 mg appropriate in this patient? Should the atorvastatin be discontinued? What medication changes if any should occur? MIRACL Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering Randomized, double-blind (n=3086) Tx = atorvastatin 80mg or placebo x 16 weeks Primary endpoint Death, nonfatal acute MI, cardiac arrest with resuscitation, or recurrent symptomatic myocardial ischemia Schwartz et al. JAMA 2001:285:1711. MIRACL Results Primary endpoint occurred in 14.8% in atorvastatin group vs 17.4% in Placebo (p=0.48) Atorvastatin 80 mg reduces recurrent ischemic events (p=0.02) LDL lowering 124 mg/dl to 72 mg/dl Schwartz et al. JAMA 2001:285:1711.

MIRACL Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering Safety and Tolerability Hepatotoxicity LFT s > 3 x ULN 2.5% for atorvastatin 80 mg vs 0.6% for placebo (p<0.001) Myotoxicity no cases of myositis reported Schwartz et al. JAMA 2001:285:1711. PROVE IT TIMI 22 RESULTS: All-Cause Death or Major CV Events in All Randomized Subjects 30 Pravastation 40mg 537/2063 (26.3%) 25 % with Event 20 15 Atorvastation 80mg 464/2099 (22.4%) 10 16% RRR at 2 years 5 (p = 0.005) 0 0 3 6 9 12 15 18 21 24 27 30 Months of Follow-up Cannon CP et al, NEJM 2004;350: 1495-504 Clinical Relevance of Achieved LDL and Achieved CRP After Treatment with Statin Therapy Cumulative Rate of Recurrent Myocardial Infarction or Coronary Death (percent) 0.00 0.02 0.04 0.06 0.08 0.10 LDLC 70 mg/dl LDLC<70 mg/dl 0.0 0.5 1.0 1.5 2.0 2.5 Follow-Up (years) Ridker PM et al, NEJM 2005;325:20-28.

PROVE-IT TIMI 22 Safety and Tolerability LFT abnormalities 1.1% in pravastatin group versus 3.3% in atorvastatin group (p<0.001) No cases of Rhabdomyolysis No significant difference in rate of myalgias Cannon CP et al. NEJM 2004;350:1495-504. Treating to New Targets (TNT) 10,001 patients randomized to atorvastatin 80 mg versus atorvastatin 10 mg All patients had stable CAD Primacy Endpoint Occurrence of first major CV event (death, non fatal MI, resuscitation after cardiac arrest, fatal or non-fatal stroke) LaRosa JC et al. NEJM 2005;305. Treating to New Targets (TNT) Results Primary endpoint occurred in 8.7% of patients on atorvastatin 80 mg vs. 10.9% for atorvastatin 10 mg P<0.001 22% relative risk reduction (P<0.001) No difference in overall mortality LaRosa JC et al. NEJM 2005;305.

Treating to New Targets (TNT) Safety and Tolerability LFT abnormalities 0.2% for atorvastatin 10 mg 2.2% for atorvastatin 80 mg P<0.001 Rates of discontinuation 5.8% for atorvastatin 10 mg 8.1% for atorvastatin 80 mg P <0.001 LaRosa JC et al. NEJM 2005;305. Risk Factors for Statin- Hepatotoxicity Advanced age Diabetes Obesity Interacting medications Case #1 MG is a 75-yr-old male with DM, and no significant CAD Hx who presents to the ER with a CC of chest pain. MG is diagnosed with a STEMI and undergoes cardiac catheterization. His fasting lipid panel revealed the following: TC = 188 mg/dl, HDL-C = 39 LDL-C = 123, TGs = 157 The patient is started on atorvastatin 80 mg

Case #1 Cont: The patient presents to clinic 6 weeks following hospital discharge and pertinent lab results are as follows: AST = 110 ALT = 123 ALK Phos = 450 Case #1 Cont. What is this patient s LDL Goal? < 70 mg/dl What percent reduction in LDL is needed? ~ 43 % Is atorvastatin at 80 mg appropriate in this patient? Probably not Should the atorvastatin be discontinued? Not always necessary What medication changes if any should occur? Reduce the dose to 40 mg and continue to monitor Hepatotoxicity - Management Obtain baseline LFTs on all patients Monitor for symptoms of hepatic injury Identify etiology Transaminase levels > 3 x ULN Use in pre-existing liver dysfunction

Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach JOSEPH SASEEN, PHARM.D., BCPS, FCCP (AQ CARDIOLOGY) Associate Professor Departments of Clinical Pharmacy and Family Medicine University of Colorado at Denver and Health Sciences Center School of Pharmacy Denver, Colorado Joseph Saseen, Pharm.D., BCPS, FCCP, is Associate Professor of Clinical Pharmacy and Family Medicine at the University of Colorado at Denver and Health Sciences Center. Dr. Saseen received his Bachelor of Science and Doctor of Pharmacy degrees from the State University of New York at Buffalo, and completed a fellowship in ambulatory care research at the University of Illinois/University of Colorado. Dr. Saseen practices as Clinical Pharmacy Specialist in the Department of Family Medicine. He is a board-certified pharmacotherapy specialist with added qualifications in cardiology. Dr. Saseen is a member of the Board of Regents and is Fellow of the American College of Clinical Pharmacy. Dr. Saseen has published several articles and book chapters related to cardiovascular disease pharmacotherapy. He has received many teaching awards at the University of Colorado. In May 2006, Dr. Saseen was honored as the recipient of the President s Excellence in Teaching Award.

Understanding Statin Myopathy and Avoiding Clinical Inertia Joseph Saseen, Pharm.D., BCPS, FCCP (AQ Cardiology) Associate Professor Departments of Clinical Pharmacy & Family Medicine University of Colorado at Denver Health Sciences Center Denver, Colorado Case #2 GG is a 56-yr-old man with a past medical history of hypertension and dyslipidemia. Smokes, is obese (waist circumference is 45, BMI is 32 kg/m 2 ), and Framingham Risk score is 18% Medications: Simvastatin 40 mg daily at bedtime, aspirin 81 mg daily, lisinopril 10 mg daily, hydrochlorothiazide 25 mg daily Fasting Labs: TC = 180 mg/dl, HDL-C = 39 mg/dl LDL-C = 95 mg/dl, TGs = 180 mg/dl glucose 110 mg/dl all other labs, including a TSH are within normal limits. Case #2 cont. GG has recently read information from the internet about muscle-related statin side effects. He has had muscle soreness for many years now, but did not think it was a problem. He reported this to his physician, who then measured his creatine kinase; it was 400 IU/L (normal: 0-200). GG is now concerned about continuing his statin.

Case #2 Reflective Questions What are his goals of therapy, and what is the benefit of statin therapy? Fear of myopathy is a barrier to treatment. Does simvastatin have to be stopped because of his muscle symptoms? What medication changes should be implemented? NCEP ATP III: 2004 Report Risk Category High Risk * CHD or equivalents (10-yr risk > 20%) Moderately High Risk * 2+ risk factors (10-yr risk 10 to 20%) Moderate Risk 2+ risk factors (10-yr risk < 10%) Lower Risk 0 to 1 risk factors LDL-C goal (mg/dl) < 100 (Optional <70) # < 130 (Optional < 100) < 130 < 160 # Very high risk favors < 70 mg/dl * High risk or moderately high with lifestyle-related risk should be on therapeutic lifestyle changes regardless of LDL-C, and should achieve at least a 30 to 40% LDL-C reduction 10-yr risk of CHD based on Framingham Scoring Circulation 2004; 110:227-239. AHA/NHLBI Scientific Statement Metabolic Syndrome Diagnostic Criteria Measure (3 of 5 constitutes diagnosis) Elevated waist circumference (in) Elevated TGs (mg/dl) Reduced HDL-C (mg/dl) Elevated BP (mm Hg) Elevated fasting glucose (mg/dl) Cut Points 40 (men), 35 (women) 150 or drug therapy < 40 (men), < 50 (women) or drug therapy 130/85 or drug therapy 100 or drug therapy Circulation. 2005;112:e285-e290.

Cholesterol Treatment Trialists Collaborators Meta-analysis,14 randomized controlled trials (n=90,056) Major Vascular Events (per 1 mmol/l LDL-C reduction) Primarhy Prevention* Control Statin Post-MI* 0 5 10 15 20 25 30 *p<0.001 Event Rate (% ) Lancet 2005;366:1267-1278. ASCOT-Lipid Lowering Arm 10,305 primary prevention patients, multiple CV risk factors randomized to placebo or atorvastatin 10 mg daily for 3.3 yrs Mean baseline LDL-C 133 mg/dl decreased to 90 mg/dl Nonfatal MI & CHD Death (%) 4 3 2 1 Placebo Atorvastatin 10 mg 0 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Years 36% reduction p=0.0005 Lancet 2003;361:1149-58. ATP III: 2004 Update Doses that Attain 30-40% LDL-C Reductions Drug Atorvastatin (Lipitor ) Lovastatin (Mevacor ) Pravastatin (Pravachol ) Simvastatin (Zocor ) Fluvastatin (Lescol ) Rosuvastatin (Crestor ) Dose (mg/d) 10 40 40 20-40 40-80 5-10 LDL-C reduction (%) 39 31 34 35-41 25-35 39-45 Circulation 2004; 110:227-239.

National Lipid Association (NLA) Statin Safety Assessment Task Force Definitions describing muscle findings in patients taking statins: Myopathy* Complaints of myalgia (muscle pain or soreness), weakness, and/or cramps, plus Elevation in serum CK >10 x ULN Rhabdomyolysis CK 10,000 > IU/L, or CK >10 x ULN plus an elevation in serum creatinine or medical intervention with IV hydration Am J Cardiol 2006;97(suppl 8A):89C 94C. ACC/AHA/NHLBI Clinical Advisory Risk Factors for Statin Myopathy Advanced age (esp. > 80 yrs, women >men) Severe chronic kidney disease Impaired liver function Perioperative periods Alcohol abuse Large quantities of grapefruit juice (certain statins) Interacting medications Hypothyroidism J Am Col Cardiol 2002;40(3):568-579. NLA Recommendations Muscle and Statin Safety 1. Rule out other etiologies of muscle symptoms or an increased CK level. 2. Consider a baseline CK in patients who are at high risk of experiencing a muscle toxicity. 3. Do not measure CK in asymptomatic patients. 4. Appropriately counsel patients about the increased risk of muscle complaints. 5. Measure CK in symptomatic patients to help gauge the severity and guide therapy. Am J Cardiol 2006;97(suppl 8A):89C 94C.

NLA Recommendations Muscle and Statin Safety 6. Intolerable muscle symptoms stop statin therapy regardless of CK; once resolved restart the same/different statin at same/lower dose. 7. Tolerable muscle complaints or asymptomatic with a CK < 10 the ULN, continue statin therapy at the same or reduced doses. 8. Rhabdomyolysis, stop statin therapy and treat accordingly; once recovered, re-evaluate the risk vs benefit of statin therapy. Am J Cardiol 2006;97(suppl 8A):89C 94C. Statin Pharmacokinetic Profiles Half-life* (hr) Hydrophilic CYP Metabolism Atorvastatin 14 No 3A4 Fluvastatin < 3, 9 (XL) No 2C9 Lovastatin 3-4 No 3A4 Pravastatin 77 Yes None Rosuvastatin 19 Yes 2C9, 2C19 Simvastatin 1.9 No 3A4 *Elimination half-life of drug and metabolites, if any CK Elevations and LDL-C Reduction Cerivastatain (0.2, 0.3, 0.4, 0.8 mg) Pravastatin (20, 40 mg) CK >10 ULN (%) 3.0 2.5 2.0 1.5 1.0 0.5 Simvastatin (40, 80 mg) Atorvastatin (10, 20, 40, 80 mg) Rosuvastatin (10, 20, 40 mg) 0.0 20 25 30 35 40 45 50 55 60 65 70 LDL-C Reduction (%) Am J Cardiol 2006;97[suppl]:44C 51C.

Case #2 Reflective Questions What are his goals of therapy, and what is the benefit of statin therapy? LDL-C < 100 mg/dl; Will decrease risk of CV events Fear of myopathy is a barrier to treatment. Does simvastatin have to be stopped because of his muscle symptoms? No. It is neither myopathy nor rhabdomyolysis, and is not considered intolerable What medication changes should be implemented? Continue dyslipidemia regimen and promote other risk reduction strategies (weight loss, smoking cessation) Case #3 RP is a 65-yr-old woman on atorvastatin 10 mg daily Past medical history: type 2 diabetes, hypertension, dyslipidemia, and an ischemic stroke Medications: Atorvastatin 10 mg daily, aspirin 81 mg daily, losartan 100 mg daily, hydrochlorothiazide 25 mg daily, metformin 1000 mg twice daily, insulin glargine 30 U daily in the evening Fasting Labs: TC = 185 mg/dl, HDL-C = 45 mg/dl LDL-C = 90 mg/dl, TGs = 250 mg/dl A1C is 6.8 mg/dl (target < 7 mg/dl for diabetes) all other labs, within normal limits RP s provider is not inclined to intensify therapy Case #3 Reflective Questions: What are her goals of therapy? Is single drug therapy as effective as combination drug therapy? Clinical Inertia is a barrier to treatment. What is the evidence supporting treatment of this type of patient?

NCEP ATP III: 2004 Report Risk Category High Risk * CHD or equivalents (10-yr risk > 20%) Moderately High Risk * 2+ risk factors (10-yr risk 10 to 20%) Moderate Risk 2+ risk factors (10-yr risk < 10%) Lower Risk 0 to 1 risk factors LDL-C goal (mg/dl) < 100 (Optional <70 )# < 130 (Optional < 100) < 130 < 160 # Very high risk favors < 70 mg/dl. * High risk or moderately high with lifestyle-related risk should be on therapeutic lifestyle changes regardless of LDL-C, and should achieve at least a 30 to 40% LDL-C reduction. 10-yr risk of CHD based on Framingham Scoring. Circulation 2004; 110:227-239. Dyslipidemia Goal Values Primary target: LDL-C Secondary target: Non-HDL-C Only if LDL-C goal met and if TG 200 mg/dl Always 30 mg/dl higher than LDL-C goal Tertiary target: HDL-C If Metabolic Syndrome and only after LDL-C and non-hdl-c goals are met Raise HDL-C to extent possible with standard therapies to 40 mg/dl (men), 50 mg/dl (women) Circulation. 2005;112:e285-e290. Lipid-Lowering Therapies Statins (atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin) Bile Acid Sequestrants (colesevelam, cholestyramine, colestipol) Nicotinic Acid Fibric Acid Derivatives (gemfibrozil, fenofibrate) Cholesterol Absorption Inhibitor (ezetimibe) Omega-3-acid (prescription strength fish oil) LDL-C 18-63% 15-30% 5-25% 5-20 or 18% 9% 45% JAMA 2001;285:2486. Zetia [package insert] Merck-Shering-Plough Pharmaceuticals; 2003. Crestor [package insert] Astra-Zeneca; 2003. Omacor [package insert] Reliant Pharmaceuticals; 2005.? HDL-C 5-15% 3-5% 15-35% 10-20% 1% TG 7-30% 0 or 20-50% 20-50% 7%

STELLAR Trial Statin Therapies for Elevated Lipid Levels compared Across doses to Rosuvastatin 6-week, parallel groups, open-label study (n=2431) % LDL-C Change from Baseline. 0-10 -20-30 -40-50 -60 Pravastatin Simvastatin Atorvastatin Rosuvastatin 10mg 20mg 40mg 80mg Am J Cardiol 2003;93:152-160. Ezetimibe Added to a Statin Double-blind, controlled trial 769 patients not at LDL goal while on statin monotherapy Randomized to placebo or ezetimibe 10 mg daily * P < 0.001 for differences 80 60 40 20 Placebo 25.1 Ezetimibe 18.9 71.5 3.7 0 Mean % LDL % at Goal Reduction Am J Cardiol 2002;90:1084-91. % of Patietns (n=998) 100 80 60 40 20 Clinical Inertia in Diabetes NHANES 1999-2002 49.9 39.6 % of Patietns (n=998) 100 80 60 40 20 36 <100 mg/dl 100-129 mg/dl >/= 130 mg/dl 30.8 33.2 0 A1C < 7% BP < 130/80 mmhg 0 LDL-Cholesterol Diabetes Care 2006;29:531-37.

STATIN wors e The Heart Protection Study (HPS) VASCULAR EVENT by PRIOR DISEASE Baseline STATIN PLACEBO Risk ratio feature (10,269) (10,267) STATIN better STATIN worse Prior coronary disease Yes 1459 (21.8%) 1841 (27.5%) No 574 (16.1%) 744 (20.8%) Prior cerebrovascular disease Yes 406 (24.7%) 488 (29.8%) No 1627 (18.9%) 2097 (24.3%) Prior diabetes Yes 601 (20.2%) 748 (25.1%) No 1432 (19.6%) 1837 (25.2%) ALL PATIENTS 2033 (19.8%) 2585 (25.2%) 0.4 0.6 0.8 1.0 1.2 1.4 Lancet 2002;360:7-22. Collaborative AtoRvastatin Diabetes Study (CARDS) 2838 primary prevention patients with type 2 diabetes randomized to placebo or atorvastatin 10 mg daily for 3.9 yrs Mean baseline LDL 118 mg/dl decreased to 77 mg/dl Primary Endpoint: Major CV Event (%) 15 10 5 0 Placebo Atorvastatin 10 mg Years 0.0 1.0 2.0 3.0 4.0 5.0 37% reduction p=0.001 Lancet 2004;364:685-696. Treat to New Targets (TNT) Trial Sub-analysis of 1501 patients with CHD and diabetes Randomized to atorvastatin 10 mg or 80 mg daily for 5 yrs 25 Major CV event (%) 20 15 10 5 10 mg atorvastatin Mean LDL = 99 mg/dl 80 mg atorvastatin Mean LDL = 77 mg/dl 25% RR reduction p=0.026 0 0 1 2 3 4 5 6 Time (years) Diabetes Care 2006;29:1220-1226.

Stoke Prevention by Aggressive Reduction in Cholesterol (SPARCL) 4731 patients with a history of stroke or TIA Randomized, doubleblind, to placebo or atorvastatin 80 mg/day x 4.9 years Mean LDL-C (mg/dl): placebo 129 atorvastatin 72 % Patients 15 10 5 0 Placebo Atorvastatin 80 mg/d p=0.03 Primary Endpoint: Stroke JAMA 2006;355:549-559. Case #3 Reflective Questions What are her goals of therapy? LDL-C < 70 mg/dl Is single drug therapy as effective as combination drug therapy? Depends on agents used combination regimens can provide robust reductions in LDL-C Clinical Inertia is a barrier to treatment. What is the evidence supporting treating this type of patient? Lowering LDL-C further in diabetes and in ischemic stroke provides additional CV event risk reduction

Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach R E F E R E N C E S 1. Schwartz GG, Olsson AG, Ezekowitz MD, et al. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial. JAMA 2001;285(13):1711-8. 2. Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med 2004;350(15):1495-504. 3. Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and Management of the Metabolic Syndrome. An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Executive Summary. Circulation 2005. 4. 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(2):227-39. 5. Briel M, Schwartz GG, Thompson PL, et al. Effects of early treatment with statins on short-term clinical outcomes in acute coronary syndromes: a meta-analysis of randomized controlled trials. JAMA 2006;295(17):2046-56. 6. Hulten E, Jackson JL, Douglas K, George S, Villines TC. The effect of early, intensive statin therapy on acute coronary syndrome: a meta-analysis of randomized controlled trials. Arch Intern Med 2006;166(17):1814-21. 7. Gotto AM, Jr. Statins, cardiovascular disease, and drug safety. Am J Cardiol 2006;97(8A):3C-5C. 8. Nissen SE, Nicholls SJ, Sipahi I, et al. Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: the ASTEROID trial. JAMA 2006;295(13):1556-65. 9. American Heart Association. Heart Disease and Stroke Statistics - 2005 Update. In. Dallas, TX: American Heart Association; 2006. 10. Bays H. Statin safety: an overview and assessment of the data--2005. Am J Cardiol 2006;97(8A):6C-26C. 11. McKenney JM, Davidson MH, Jacobson TA, Guyton JR. Final conclusions and recommendations of the National Lipid Association Statin Safety Assessment Task Force. Am J Cardiol 2006;97(8A):89C-94C. 12. Jacobson TA. Statin safety: lessons from new drug applications for marketed statins. Am J Cardiol 2006;97(8A):44C-51C. 13. Ross R, Glomset JA. The pathogenesis of atherosclerosis (first of two parts). N Engl J Med 1976;295(7):369-77. 14. Vogel RA. Cholesterol lowering and endothelial function. Am J Med 1999;107(5):479-87.

Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach 15. Fuster V, Badimon L, Badimon JJ, Chesebro JH. The pathogenesis of coronary artery disease and the acute coronary syndromes (2). N Engl J Med 1992;326(5):310-8. 16. LaRosa JC, Grundy SM, Waters DD, et al. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med 2005;352(14):1425-35. 17. Baigent C, Keech A, Kearney PM, et al. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet 2005;366(9493):1267-78. 18. Sever PS, Dahlof B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet 2003;361(9364):1149-58. 19. 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. 20. Jones PH, Davidson MH, Stein EA, et al. Comparison of the efficacy and safety of rosuvastatin versus atorvastatin, simvastatin, and pravastatin across doses (STELLAR* Trial). Am J Cardiol 2003;92(2):152-60. 21. Gagne C, Bays HE, Weiss SR, et al. Efficacy and safety of ezetimibe added to ongoing statin therapy for treatment of patients with primary hypercholesterolemia. Am J Cardiol 2002;90(10):1084-91. 22. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002;360(9326):7-22. 23. Colhoun HM, Betteridge DJ, Durrington PN, et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 2004;364(9435):685-96. 24. Amarenco P, Bogousslavsky J, Callahan A, 3rd, et al. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006;355(6):549-59.

Evidence-based Strategies for the Management of Dyslipidemia: A Case Study Approach FACULTY DISCLOSURE STATEMENTS ASHP Advantage requires that faculty members disclose any relationships (e.g., shareholder, recipient of research grant, consultant or member of an advisory committee) that the faculty may have with commercial companies whose products or services may be mentioned in their presentations. The existence of these relationships is provided for the information of attendees and should not be assumed to have an adverse impact on faculty presentations. The faculty reports the following relationships: Joseph Saseen, Pharm.D., BCPS, FCCP (AQ Cardiology) Dr. Saseen reports that he serves on the Speakers Bureau for AstraZeneca. Barbara S. Wiggins, Pharm.D., BCPS (AQ Cardiology) Dr. Wiggins reports that she serves on the Speakers Bureau for Pfizer.