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