PHARMACOTHERAPY REVIEW CNS STIMULANTS for treatment of ...

More documents

Recommendations

Info

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
Table 3. Typical Dose-Related Reduction of LDL with StatinsDrug Daily Dose (mg) % ReductionAtorvastatin 1020408039435060Fluvastatin 204080Lovastatin 204080Pravastatin 102040Simvastatin 510204080222536273242223234Data derived from manufacturer prescribing information (Lipitor/Pfizer,Lescol/Novartis, Mevacor/Merck, Zocor/Merck and Pravachol/Bristol-Myers Squibb).2630384147Table 4 Impact of Selected Statin Doses on HDL and TriglyceridesDrug Dosage ↑ HDL (%) ↓ TG (%)Atorvastatin 80 mg/day 6 29Fluvastatin 40 mg/day 8 10Lovastatin 80 mg/day 8.6 16Pravastatin 40 mg/day 12 24Simvastatin 80 mg/day 12 18Data derived from manufacturer prescribing information (Lipitor/Pfizer, Lescol/Novartis,Mevacor/Merck, Zocor/Merck and Pravachol/Bristol-Myers Squibb).Most patients with CHD require only a 30% LDL reduction to achieve their NCEP-ATP III goal. 24This is attainable with mid-range doses of most statins. Relatively few patients require LDLreduction of 40% to 60% to achieve their NCEP-ATP III goal.Statins decrease cholesterol synthesis by the liver by inhibiting the hepatic enzyme HMG-CoAreductase. The net effect is lowering of cholesterol-carrying lipoproteins, the most significant beingLDL.Several large scale, randomized clinical trials provide convincing evidence that statins are effective inreducing CHD events in both primary and secondary prevention. Much of the evidence relates tolovastatin, pravastatin and simvastatin (see Table 5 and Appendix A).4
Page 1 and 2: PHARMACOTHERAPY REVIEWCNS STIMULANT
Page 3 and 4: D. CNS Stimulants Indicated to Trea
Page 5 and 6: Product Group Onset of Action (min)
Page 7 and 8: APPENDIX ADSM-IV-TR DIAGNOSTIC CRIT
Page 9 and 10: BIBLIOGRAPHY123456789101112American
Page 11 and 12: 252627282930Pelham WE, Greenslade K
Page 13: III.TREATMENT GUIDELINESClinical tr
Page 17 and 18: Muscle toxicity is the most serious
Page 19 and 20: Another drug, relatively new to the
Page 21 and 22: Statins (continued)Grapefruit juice
Page 23 and 24: Committee that all strengths of the
Page 25 and 26: AFCAPS/TexCAPS(The Air Force/ Texas
Page 27 and 28: 4S(Scandinavian Simvastatin Surviva
Page 29 and 30: CARE(The Cholesterol and Recurrent
Page 31 and 32: PPP(Prospective Pravastatin Pooling
Page 33 and 34: MRC/BHF Heart Protection Study• S
Page 35 and 36: BIBLIOGRAPHY12345678910111213Americ
Page 37 and 38: 2829303132333435Ballantyne CM, Andr
Page 39 and 40: the American Medical Association (J
Page 41 and 42: In Table 2 of the Beer’s List (At

PHARMACOTHERAPY REVIEW CNS STIMULANTS for treatment of ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?