Friday, April 4, 2008

Should I Take Zetia or Vytorin?

Effectiveness of the cholesterol medications Zetia (ezetimibe) and Vytorin (simvastatin/ezitimibe) were called into question this week in well-publicized reports from the American College of Cardiology meetings, as published in the New England Journal of Medicine.

Specifically, the ENHANCE trial found that although adding ezetimibe to maximal statin doses over 24 months effectively lowered bad cholesterol (LDL) and inflammatory markers of heart disease risk, it did nothing to decrease the size of cholesterol plaques in the large neck arteries (carotid arteries). Such plaque size is a well-documented marker for heart attack risk.

Importantly, the ENHANCE trial does not raise safety concerns about ezetimibe, but rather questions its effectiveness in achieving one clinical outcome. Additionally, the study was conducted on a select population of patients with familial hypercholesterolemia and a very high mean LDL level of 317. The patients did not achieve the target cholesterol goals known to you loyal Bloggers. These facts make the study outcome difficult to interpret and somewhat controversial.

So, what should you do if you are taking these medicines or if you have non-goal cholesterol levels?
* Achive LDL levels at ATP III-recommended levels.
* Utilize lifestyle changes like diet and exercise in addition to optimal sugar and blood pressure control.
* Realize that statins are the first drugs of choice, and should be titrated to the highest tolerated dose to achieve the target.
* Know that if optimal statin dosing does not achieve the goal, additional therapy is needed. Options include niacin, bile acid resins (like Colestipol), psyllium (like Metamusil), and fibrates (like Tricor), in addition to cholesterol absorption inhibitors like ezitimibe (Zetia). Some authorities believe that the non-ezetimibe options should be tried first given results of prior studies.

Ongoing trials will help clarify these issues further. Stay tuned to the Blog, and, as always, if your levels are not at the goal, ask your doctor "why not?"

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