Nearly one out of every three individuals in the US dies of heart disease or stroke, but the risk can be reduced with effective treatment, including statin therapy. With hypercholesterolemia as one of the most preventable risk factors for atherosclerotic cardiovascular disease, the use of cholesterol-lowering medications for its prevention is increasing and its importance has been emphasized within national cholesterol treatment guidelines.

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The CDC's National Health and Nutrition Examination Survey results¹ highlight recent trends associated with cholesterol-lowering medications. Among adults in the US aged 40 and over during 2003–2012, the percentage using a cholesterol-lowering medication in the past 30 days increased from 20% to 28%. Statin use overall increased from 18% to 26%, and by 2011–2012, 93% of adults who were using a cholesterol-lowering medication used a statin. The use of cholesterol-lowering medications increased with age, with 17% of adults aged 40–59 and 48% of adults aged 75 and over taking them. Cholesterol-lowering medications were used by approximately 71% of adults with cardiovascular disease and 54% of adults with hypercholesterolemia. Use of cholesterol-lowering medications was more prevalent among adults aged 40–64 with health insurance than those without it. Of prescription cholesterol-lowering medications, the most commonly used product was simvastatin, with 42% reporting its use. Following this was atorvastatin at 20.2%, pravastatin at 11.2%, rosuvastatin at 8.2%, and lovastatin at 7.4%.

Although prospective studies are still needed, there has been research² showing that statins are likely to be cost-effective in primary prevention of cardiovascular disease without increasing the risk of serious adverse events such as cancer. It was also shown that statins significantly reduce the incidence of all-cause mortality and major coronary events as compared to control in both primary and secondary prevention. The research also brought to light the potential differences between individual statins, which are not fully explained by their LDL cholesterol-reducing effects. The following observations were noted, and these and other differences should continue to be investigated:

• Atorvastatin and fluvastatin were significantly more effective than rosuvastatin at comparable doses
• In participants with cardiovascular disease, statins significantly reduced deaths and major coronary events
• Atorvastatin was significantly more effective than pravastatin and simvastatin for secondary prevention of major coronary events
• In primary prevention, statins significantly reduced deaths and major coronary events with no differences among individual statins

An approach under consideration for primary cardiovascular disease prevention is the use of aspirin; however, according to the FDA there is not enough evidence to support its use in this manner. Aspirin has demonstrated only a modest improvement in clinical outcomes when tested in trials for use in primary prevention. Additionally, there are serious risks associated with the use of aspirin, including the risk of stomach and brain bleeding. Therefore, the use of aspirin for primary prevention should be approached with caution.

FDA-approved therapies for lowering cholesterol include those presented in PDR's Cholesterol-Lowering Agents table (content based on FDA-approved labeling as of March 2014 and included as part of the 2015 PDR Nurse's Drug Handbook). New FDA approvals continue to emerge that offer even more therapeutic options to manage hypercholesterolemia. Recent examples include:

• Epanova (omega-3-carboxylic acids), as an adjunct to diet for reduction of TG levels in adults with severe hypertriglyceridemia
• Juxtapid (lomitapide), as an adjunct to a low-fat diet and other lipid-lowering treatments, including LDL apheresis where available, to reduce LDL, total cholesterol, apolipoprotein B, and non-HDL in patients with homozygous familial hypercholesterolemia
• Kynamro (mipomersen sodium), as an adjunct to lipid-lowering medications and diet to reduce LDL, apolipoprotein B, total cholesterol, and non-HDL in patients with homozygous familial hypercholesterolemia
• Liptruzet (atorvastatin/ezetimibe), as adjunctive therapy to diet for the treatment of elevated LDL in patients with primary or mixed hyperlipidemia
• Omtryg (omega-3-acid ethyl esters), as an adjunct to diet to reduce TG levels in adult patients with severe hypertriglyceridemia

Keep informed by using PDR.net as a resource for thousands of available products. Stay current on alerts and specific product labeling by providing updated contact information. To have updated drug information, full labeling, and safety warnings integrated into your electronic prescribing system automatically, and at no cost to you, be sure to request PDR drug data feeds, including PDR BRIEF.

Salvatore Volpe, MD, FAAP, FACP, CHCQM
Chief Medical Officer
PDR

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