Matthew Sorrentino, MD, on Statin Therapy
Maintaining normal cholesterol levels plays an important part in reducing the risks for cardiovascular disease, stroke, and hypertension, according to the Centers for Disease Control and Prevention (CDC). However, approximately 1 in 3 US adults has high cholesterol, putting them at a higher risk for developing these conditions.1
Several measures exist to help lower cholesterol, including medication and lifestyle changes. Medications such as statins, which are known to slow the liver’s production of cholesterol, are often prescribed to help reduce low-density lipoprotein (LDL) cholesterol levels.
Consultant360 spoke with Matthew Sorrentino, MD, FACC, FASH, professor of medicine at University of Chicago Medicine in Illinois, who provided us with an in-depth explanation of statin therapy.
Consultant360: Which patients qualify for statin treatment? Are there limits or restrictions?
Matthew Sorrentino: There are 4 groups of patients who have been shown to experience a reduction in cardiovascular events when treated with a statin medication. These groups include:
- Patients with clinical atherosclerotic cardiovascular disease.
- Primary prevention patients with LDL cholesterol levels of 190 mg/dl or higher.
- Patients age 40 to 75 years with diabetes and LDL cholesterol levels of 70 to 189 mg/dl.
- Primary prevention patients age 40 to 75 years without diabetes with an estimated 10-year atherosclerotic cardiovascular disease risk of 7.5% or higher based on the Pooled Cohort Risk Equation.
Statins can also be considered in individuals with a 10-year atherosclerotic cardiovascular disease risk of 5% to 7.5%.
C360: How do practitioners treat patients who are statin intolerant? What alternative medications are there?
MS: Practitioners can change the type of statin medication prescribed to reduce adverse effects, since a statin metabolized by a different enzymatic pathway in the liver may be better tolerated than other statins. Statins with a longer half-life may be used with alternative dosing schedules such as a few times a week or every other day dosing. Rosuvastatin with a 19 hour-half-life and atorvastatin with an 11- to 24-hour half-life (parent drug and active metabolite) are likely to have the best efficacy using intermittent dosing. Combination therapy with a statin plus an intestinal agent can be used in individuals who can only tolerate a low-dose statin to achieve the efficacy of a higher-dose statin.
Patients who cannot tolerate even intermittent dosing of statins will need different approaches to cardiovascular risk reduction. An optimal lifestyle modification program with improved diet and exercise can achieve significant risk reduction that can approach the benefit of statin therapy. There are a number of additional classes of cholesterol-lowering medications that can be considered as alternatives to statins, including intestinal agents (bile acid sequestrants and ezetimibe), niacin, fibrates, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors.
C360: How do statins compare to PCSK9 inhibitors?
MS: PCSK9 inhibitors are very effective LDL-lowering medications. LDL-lowering is achieved when using these agents as monotherapy, in statin-intolerant patients, and in combination with statin therapy. There are two approved agents available, and both have reported a mean change in LDL of more than 60% in patients who are already treated with maximally tolerated statin therapy.
As monotherapy, PCSK9 inhibitors lower LDL to the same extent as high doses of high-potency statins. Outcome data with PCSK9 agents is gradually becoming available. Early in 2017, a study using a PCSK9 inhibitor in combination with a high-dose statin achieved further significant cardiovascular risk reduction in a group of high-risk patients. Outcome studies with PCSK9 monotherapy are ongoing.
Statins are considered first-line therapy because of multiple randomized long-term trials showing significant cardiovascular risk reduction and no accumulation of side effects in individuals that can tolerate statins.
C360: What key takeaways about statin therapy would you like to leave our readers with?
MS: Practitioners should know about the potential adverse effects of statins and how to try to mitigate the side effects. Alternative therapies to statins, including an optimal lifestyle modification program and different medications such as PCSK9 inhibitors, are also key. It is important for practitioners to know that alternative therapies to statins can achieve significant cardiovascular risk reductions.
—Christina Vogt
Reference:
1. Cholesterol. Centers for Disease Control and Prevention (CDC). Updated on November 13, 2017. https://www.cdc.gov/cholesterol/index.htm. Accessed on November 16, 2017.
2. Sorrentino M. Lipid treatment of the statin intolerant patient. Presented at: American Medical Forum (AMF) Update CME: Internal Medicine and Primary Care; November 9 to 12, 2017; Chicago, IL.