Epidemiological studies (the most recent EUROASPIRE III and DYSIS) have clearly shown that despite treatment with statins (also considered high-power) the majority of patients with coronary artery disease and / or diabetes is far from reaching lipid targets recommended by international guidelines.
One possible explanation of this important phenomenon can be identified definitely in poor adherence to therapy by the patient or practice not just rare cyclical treatments, but especially one that inhibit hepatic cholesterol synthesis means controlling part of the problem of hypercholesterolemia our patient. In fact, cholesterol comes from two main sources: the hepatic synthesis and intestinal absorption, which are absolutely equivalent in terms of intake of cholesterol in the body.
Statins act only in an effective manner, solely on the hepatic synthesis, without any action on intestinal, where there is a pool of cholesterol format for the 2 / 3 from the origin of biliary cholesterol and the remaining third coming from the diet. Moreover, it was also shown (see Miettinem or Assmann) that when you go to inhibit a single source (either intestinal or hepatic), the other tends to increase through a mechanism of homeostatic balance. It follows that the only inhibiting hepatic synthesis of response the body will tend to increase the intestinal absorption and vice versa. It follows what is commonly called the "rule of 6" so that for each doubling of the dose of a statin will be an incremental reduction in LDL cholesterol of only 6% (as cited in the NCEP ATP III guidelines in 2004).
So it always pays to carefully evaluate the benefit of statin dose alone because as is well known, increasing the dosage until maximum levels are likely to significantly increase the incidence of adverse events compared with a low clinical benefit.
As already happens in other therapeutic areas, such as hypertension, one of the options for achieving the target is to maintain a standard dose statin and associate an intestinal absorption’s inhibitor of cholesterol such as ezetimibe for maximum effect with a good safety profile and better patient compliance.
The INCROSS study demonstrated, that the combination ezetimibe / simvastatin 10/20 reduce LDL cholesterol (see Figure 1) more than rosuvastatin 10mg and bring a greater proportion of patients to the recommended target.
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