PHARMACOTHERAPY REVIEW CNS STIMULANTS for treatment of ...

To enhance the potential for CHD risk reduction, NCEP-ATP III produced two majorrecommendations in addition to treatment decision points to lower LDL-cholesterol levels to goal(Table 1).First, NCEP-ATP III guides identification of patients with metabolic syndrome and recommendstherapeutic lifestyle changes focusing on weight reduction and exercise, utilization of drugs to lowertriglycerides and raise HDL, reduce thrombogenic potential with daily aspirin use, and treathypertension effectively. 21Second, NCEP-ATP III recommends that secondary treatment targets, defined by non-HDL (totalcholesterol minus HDL) be established for patients who have triglyceride levels > 200 mg/dL afterLDL goals have been achieved. (see Table 2). 21 Time and additional clinical trials will documentthe value of meeting non-HDL goals.Table 2. LDL and Non-HDL Goals for Patients with Triglyceride Levels > 200 mg/dL 19Risk StatusLDLPrimary GoalNon-HDLSecondary GoalCHD or risk equivalent a < 100 mg/dL < 130 mg/dL> 2 risk factors b < 130 mg/dL < 160 mg/dL< 2 risk factors b < 160 mg/dL < 190 mg/dLabRisk equivalents are diabetes, metabolic syndrome, greater than 20% 10-year CHD risk.Risk factors are man over 45 years of age, woman over 55 years of age, family history of premature CHD, highblood pressure, HDL below 40 mg/dL, current cigarette smoking.IV.TREATMENT CHALLENGESThe NCEP-ATP III guidelines increased the number of patients who are appropriate candidates forLDL-lowering from approximately 13 million to approximately 32 million. Of these, approximately20 million would be candidates for an LDL goal of 100 mg/dL or less. Before NCEP-ATP III, it was22, 23estimated that only about 18% with an LDL-cholesterol goal of < 100 mg/dL reached their goal.Further, how to best achieve non-HDL goals is very challenging.LDL TREAMENT GOALS“Statins” have been and remain the drugs of first choice to lower LDL-cholesterol. LDL-cholesterollowering may also provide risk reduction by stabilizing plaque, reducing inflammation and restoringendothelial function.Dose-related reduction in LDL-cholesterol, according to manufacturer prescribing information, isincluded in Table 3. 24 The impact of selected doses of statins on HDL and triglycerides is includedin Table 4. 243