Combination drug therapy for combined hyperlipidemia

Abstract

Combination therapy for hyperlipidemia, especially combined hyperlipidemia, may have advantages over single drug therapy, affording better improvement in lipoprotein risk factors and possibly better prevention of atherothrombotic events. Although preliminary experience has been gained using treatment combinations of niacin with statins, and fibrates with statins, few studies have focused on angiographic or clinical outcomes. Both of these treatment combinations increase the risk of drug-induced myopathy and rhabdomyolysis. Current estimates of myopathy incidence are much lower than original estimates, but the relative safety of combined therapy might depend upon employing low or moderate statin doses. Safety depends critically upon educating the patient to respond appropriately to muscle symptoms, to intercurrent illness, and to concurrent use of certain other medications. Other useful drug combinations include those derived by addition of fish oil, bile acid binding resins, or stanol esters, as well as nonstatin combinations such as niacin-resin or fibrate-niacin.

Statins: Monotherapy or Combination Strategy for the Treatment of Dyslipidemia

“…Niacin monotherapy has beneficial effects on all lipoprotein classes, including LDL-C, very low-density lipoprotein cholesterol (VLDL-C) and lipoprotein (a). Depending on the dose and formulation, it is also associated with increases in HDL-C concentration of 25-28% [28]. Combination therapy including a statin with niacin therefore has the potential for additive beneficial effects across the lipid profile, particularly in patients requiring LDL-C reduction and an increase in HDL-C levels.…”

“…It has been suggested that the incidence of myopathy with combination therapy may be lowered considerably if statin and niacin doses are limited [28], and this may also be the case for statin-fibrate combinations [56,57]. Thus, doses of each drug should be carefully titrated and kept to a minimum.…”

Nonpharmacologic and pharmacologic treatment of patients with low levels of high-density lipoprotein cholesterol

“…Niacin therapy produces beneficial effects on the entire lipoprotein profile, but its most dramatic effect is on HDL-C, increasing levels by 10% to 30% [30][31][32][33][34]. Niacin is currently available in a variety of chemical preparations, including immediate-release (regular/crystalline/IR), slowrelease (SR), and extended-release (Niaspan, KOS Pharmaceuticals, Miami, FL) forms.…”

“…Fibric acid derivatives, employed primarily in the treatment of hypertriglyceridemia, can also increase levels of HDL-C by 6% to 20% [9,30]. Serum triglycerides (TG) and HDL-C are frequently inversely related, and fibrates are most effective in increasing HDL-C in patients with concomitant hypertriglyceridemia.…”

“…Statins have fewer potent effects on HDL-C, increasing levels by 5% to 10% [30]. The Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS) investigated the effect of lovastatin in primary prevention of CHD among healthy men and women with average levels of TC (mean 221 mg/dL) and LDL-C (mean 150 mg/dL) and below-average levels of HDL-C (mean 36 mg/dL [men] and 40 mg/dL [women]).…”