1,721,395 research outputs found
Perspectives on low-density lipoprotein cholesterol goal achievement
No full textBACKGROUND: 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
Statin-induced myotoxicity : pharmacokinetic differences among statins and the risk of rhabdomyolysis, with particular reference to pitavastatin
No full text3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are the most widely prescribed therapeutic class of drugs worldwide, with established clinical benefits both in terms of improving serum lipid profiles and reducing cardiovascular events and mortality. Although statins have a favorable risk-to-benefit ratio, they have the potential to cause adverse events which can result in muscular inflammation (myositis), muscle breakdown (rhabdomyolysis) and, ultimately, kidney failure. While the incidence of rhabdomyolysis is approximately 3.4 cases per 100,000 person-years with standard-dose statin therapy, the risk of developing the condition increases substantially at higher therapeutic doses. This effect may be exacerbated by prescribing statins in combination with certain other medications because drug - drug interactions increase statin exposure by interacting with enzymes that would normally be involved in their metabolism and clearance. Co-administration of drugs that inhibit the cytochrome P450 (CYP) enzymes responsible for metabolizing statins, or that interact with the organic anion-transporting polypeptides (OATPs) responsible for statin uptake into hepatocytes, substantially increases the risk of developing myotoxicity. Such effects vary among statins according to their metabolic profile. For example, pitavastatin, a novel statin approved for the treatment of hypercholesterolemia and combined (mixed) dyslipidemia, is not catabolized by CYP3A4, unlike other lipophilic statins, and may be less dependent on the OATP1B1 transporter for its uptake into hepatocytes before clearance. Such differences in drug - drug interaction profiles among available statins offer the possibility of reducing the risk of myotoxicity among high-risk patients
New strategies for the management of patients with homozygous familial hypercholesterolaemia
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Management of homozygous familial hypercholesterolaemia--unmet needs, updated recommendations, and clinical experience with the MTP inhibitor, lomitapide : concluding comments
No full textPitavastatin: a different pharmacological profile
No full textPitavastatin, a synthetic HMG-CoA reductase inhibitor, is characterized by a cyclopropyl moiety that results in several pharmacological differences compared with other statins. These include inhibition of cholesterol synthesis and increased lipoprotein lipase expression at lower doses than other statins, and significant high-density and apolipoprotein Al-elevating activity that persists with time. Pitavastatin has a higher bioavailability (60%) than any other statin and the majority of the bioavailable fraction after oral dosing is excreted unchanged in the bile. The enterohepatic circulation of unchanged pitavastatin contributes to the prolonged duration of action, allowing once-daily, any-time dosing. Pitavastatin undergoes only minor metabolism by CYP2C9 but is not metabolized by CYP3A4. Neither pitavastatin nor its lactone form have inhibitory effects on cytochrome P450, and CYP3A4 inhibitors have no effect on pitavastatin plasma concentrations. Moreover, P-glycoprotein-mediated transport does not play a major role in the disposition of pitavastatin and pitavastatin does not inhibit P-glycoprotein activity. Pitavastatin is transported into the liver by several hepatic transporters, but organic anion-transporting polypeptide I B I inhibitors have relatively little effect on plasma pitavastatin concentrations compared with other statins. With the exception of multitransporter inhibitors, such as ciclosporin, interactions are generally of no clinical significance. As a result, pitavastatin has minimal drug-drug and drug-food interactions, making it a good treatment option in the large population of individuals with dyslipidemia who require multidrug therapy
Lecithin:cholesterol acyltransferase and vascular disease
No full textEvaluation of: Calabresi L, Baldassarre D, Castelnuovo S et al.: Functional lecithin:cholesterol acyltransferase is not required for efficient atheroprotection in humans. Circulation 120, 628-635 (2009). Lecithin:cholesterol acyltransferase (LCAT) is an HDL-associated enzyme responsible for esterifying free cholesterol to cholesteryl ester within the plasma compartment. Mutations in the LCAT gene can cause LCAT deficiency, a very rare metabolic disorder associated with two hypoalphalipoproteinemia syndromes; familial LCAT deficiency, characterized by complete lack of enzyme activity, and fish-eye disease, with a partially defective enzyme. As LCAT deficiency causes hypoalphalipoproteinemia, carriers should be at increased risk of coronary artery disease because of defective reverse cholesterol transport; however, owing to the relatively small number of cases available, this hypothesis has not been confirmed. Calabresi et al. take advantage of the availability of 13 LCAT-deficient families to investigate the extent of carotid preclinical atherosclerosis in these patients
Lipid lowering activity of drugs affecting cholesterol absorption
No full textAIM: Dietary cholesterol absorption, endogenous cholesterol synthesis and biliary cholesterol excretion regulate whole body cholesterol balance as a result of biotransformation into bile acids or direct cholesterol excretion. Recent studies have significantly advanced our understanding of intestinal sterol absorption at molecular level. This review concentrates on two major issues: the mechanisms of sterol absorption, and the currently available or experimental drugs that affect this pathway. DATA SYNTHESIS: Nuclear hormone receptors, such as the liver X, farnesoid X and retinoid X receptors, regulate the absorption of dietary sterols by modulating the transcription of several genes involved in cholesterol metabolism, The ABC proteins transport dietary cholesterol from enterocytes back to the intestinal lumen, thus limiting the amount of absorbed cholesterol. By means of the same mechanism, ABC transporters also provide an efficient barrier against the absorption of plant sterols. Phytosterols, bile acid sequestrants, ezetimibe and ACAT inhibitors are possible means of affecting these pathways. CONCLUSION: In addition to providing an insight into the molecular mechanisms of sterol absorption, these recent findings may lead to new therapeutic options for the treatment of hypercholesterolemia. This is particularly true in the case of patients at high risk of coronary artery disease requiring aggressive lipid-lowering therapy combining a statin with drugs affecting cholesterol absorption in order to ensure the optimal management of dyslipidemia
Omega-3 polyunsaturated fatty acids in the treatment of hypertriglyceridaemia
No full textHypertriglyceridaemia (HTG) is an independent risk factor for cardiovascular disease; high-risk patients with HTG, such as those with metabolic syndrome or diabetes, may benefit from hypolipidaemic therapies. Several lipid-lowering drugs act by reducing triglyceride (TG) levels, including fibrates, nicotinic acid and omega-3 fatty acids. The omega-3 polyunsaturated fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) dose-dependently reduce plasma TG levels; the effect tends to be greater in patients with higher TG levels at baseline. Evidence from clinical trials suggests that EPA+DHA doses of ≥ 2 g/day are required to achieve significant effects. The optimal TG-lowering doses of EPA+DHA are 3-4 g/day, with little evidence to support lipid-altering efficacy of doses of EPA and DHA <1g/day. Predicted changes in fasting serum TG levels at the recommended dietary intakes of EPA and/or DHA of 200-500 mg/day are -3.1% to -7.2%. Reductions of plasma TG levels at the optimal doses are from 25-35% up to 45% in the presence of severely elevated TG levels (≥ 500 mg/dl; ≥ 5.65 mmol/l), along with a reduction in non-high-density lipoprotein-cholesterol (non-HDL-C) and an increase in HDL-C. This observation has also been confirmed in statin-treated patients
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