Step 3 P-treatment: Drug Class Selection. Pharmacological and Non- Pharmacological Management...
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Transcript of Step 3 P-treatment: Drug Class Selection. Pharmacological and Non- Pharmacological Management...
Step 3
P-treatment: Drug Class Selection
Pharmacological and Non-Pharmacological Management
Dyslipidemia drug therapy
• Smoking cessation• Weight management• Regular physical exercise• Adequate blood pressure monitoring and control• Dietary management: low fat, low cholesterol
Lifestyle modification
Drug Classes
Statins
Nicotinic Acid
Fibric Acid Derivatives
Bile-Acid Binding Resins
Ezetimibe
Statins
• MOA– HMG-CoA reductase inhibitor : reduces hepatic
cholesterol synthesis• Efficacy (++++)– Significant reduction of LDL (up to 35%)– Increase in HDL (5-10 %)– Decreased triglyceride levels– Level of evidence: meta analysis
Statins - Continued
• Safety: (+++)– Risk of myositis if taken in combination with fibrates or
niacin– Not recommended in those with hepatic
derangements• Suitability (+++)– Primary concern is LDL lowering– Ease of administration: oral preparation, once a day.
• Cost: (++++)– Afordel: Php 203.25/ month at 10 mg/day
Nicotinic Acid
• MOA– Reduces production of VLDL: secondary reduction
in LDL and increase in HDL• Efficacy (+++)– Significant increase in HDL (~30%)– Decrease in LDL (~20%)– Significant decrease in Triglycerides– Long experience: reduction in coronary events and
mortality
• Safety (++)– Intolerance is common with full doses– “hot flashes” and pruritus– Precaution if used with statins
• Suitability (++)– Suboptimal LDL lowering if not at full dose
• Cost (+++)– Niaspan: Php 555 pesos / month at 500 mg/day
Nicotinic Acid- Continued
Fibric Acid Derivatives
• MOA– PPAR-alpha agonist– Reduced Apolipoprotein C-III synthesis: increased
lipoprotein lipase activity: increased VLDL clearance• Efficacy (++)– Significantly reduces triglycerides (~40%)– Increase HDL (~20%)– Reduce LDL (~15%)– Reduced CHD rates among hypercholesterolemics
• Safety (++)– Risk of developing cholelithiasis, hepatitis, and
myositis• Suitability (++)– Most benefit is seen among those with
hypertriglyceridemia and low HDL cholesterol– Taken twice a day
• Cost (++)– Nubrex: Php 1072 / month at 200 mg/day
Fibric Acid Derivatives- Continued
Bile Acid Binding Resins
• MOA– Reduces enterohepatic circulation of bile acids– Increases hepatic production of bile acids,
consuming hepatic cholesterol• Efficacy (+++)– Reducton in LDL (~20%)– Increase in triglycerides– No effect to HDL– Reduced incidence of coronary events in studies
• Safety (+++)– Interferes with absorption of fat-soluble vitamins– Caution with warfarin
• Suitability (++)– Primary effect targets LDL– Monotherapy may be insufficient– Doses need to be divided
• Cost N/A– Cost abroad is greater than that of statins
BAB Resins- Continued
Ezetimibe
• MOA– Inhibits a cholesterol transporter in the intestine,
reducing enteric absorption• Efficacy (+++)– Reduces LDL (~20%)– No significant effect on HDL and Triglycerides
• Safety (++)– Can be used in combination with statins
• Suitability (++)– Specific for LDL reduction– Monotherapy may be insufficient– Once a day dosing
• Cost (+)– Ezetrol: Php 3000/month at 10 mg/day
Ezetimibe- Continued
SummaryDrug Class Efficacy Safety Suitability Cost
Statins ++++ +++ +++ ++++
Nicotinic Acid +++ ++ ++ +++
Fibrates ++ ++ ++ ++
Resins +++ ++ ++ N/A
Ezetimibe +++ +++ ++ +
Therefore, considering the efficacy, safety and suitability and the cost of the available treatment options, STATINS is the most preferred drug class of choice.
Statins are composed of several kinds, and thus we discuss this further.
STATINSDrug class of most benefit
Locally Available Statins
Simvastatin
Atorvastatin
Rosuvastatin
Fluvastatin
Quick Info for the Different Statins
Statin Brand Name Manufacturer
Simvastatin Zocor Merck and Co.
Atorvastatin Lipitor Pfizer
Rosuvastatin Crestor Astra Zeneca
Fluvastatin Lescol Zuellig
All are 100% synthetic.** Lovastatin, example of a fungus-derived stain. Not available in the Philippines.
SummaryDrug Class Efficacy Safety Suitability Cost
Simvastatin (Afordel, 40mg) ++++ +++ ++++ +++
(P 17.33/day)Atorvastatin(Lipitor, 10mg) ++++ +++ ++++ ++
(P 34.45/day)Rosuvastin(Crestor, 10mg) ++++ +++ ++++ ++
(P 57.66/day)Fluvastatin(Lescol, 40mg) ++++ +++ ++++ ++
(P52.61/day)
Therefore, SIMVASTATIN is the best option among the statins option.
STEP 4Prescription Writing
A.Dionisia 62 Female
Simvastatin, 40 mg tablet 30Inomin 1x tuwing gabi.
Dr. Manny Kalayaan123456
Date: November 17, 2010
Manny Kalayaan, MD, FPCP, FPMID
Philippine General HospitalMon-Friday 9am to 4pm
0917-12345678
Patient: AD Date: November 17, 2010 Address: Manila Age/Sex: 62/F
R/ Simvastatin 40 mg tablet #30
Sig: Inomin 1 tablet sa gabi
Dr. Manny KalayaanLic. No.123456