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LDL-Cholesterol – Lower is Better . Reducing CHD in high risk patients. Contents. Contents Slide Presentation summary Title slide: LDL-Cholesterol – Lower is Better: Reducing CHD in high risk patients OPTIONAL SLIDE #1: Cardiovascular disease and cholesterol: Key facts

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Ldl cholesterol lower is better

LDL-Cholesterol – Lower is Better

Reducing CHD in high risk patients


Contents

Contents

  • Contents Slide

  • Presentation summary

  • Title slide: LDL-Cholesterol – Lower is Better: Reducing CHD in high risk patients

  • OPTIONAL SLIDE #1: Cardiovascular disease and cholesterol: Key facts

  • Identifying ‘higher risk’ patients

  • Why treat high risk patients?

  • The impact of lowering LDL-C: Lower is better – however you achieve it

  • Beneficial CV risk reduction with lowering LDL-C – however you achieve it

  • OPTIONAL SLIDE #2: What does NICE advise for high risk patients?

  • What are your options?

  • Title slide: Treatment options: What the trials say

  • OPTIONAL SLIDE #3: Trial overview

  • Lowering LDL-C: Treatment options

  • ALTERNATIVE VERSION TO SLIDE #12: Lowering LDL-C: Treatment options

  • Treating high risk patients: What are your choices?

  • NICE recommendations for treatment with ezetimibe

  • OPTIONAL SLIDE #4: Safety data for ezetimibe

  • What NICE says... Patients with Type 2 diabetes

  • What NICE says... Patients with Familial Hypercholesterolaemia

  • In summary: Treating higher risk patients

  • OPTIONAL SLIDE #5 Additional Slides


Presentation summary

Presentation summary

Cholesterol and CVD, leading cause of death and high cost

Reducing LDL-C levels significantly reduces the risk of CHD

Treatment strategies for the cohort of high risk patients

Review evidence, clinical trials, clinical practice and NICE Guidance to manage this difficult group of patients


Ldl cholesterol lower is better

Cardiovascular disease and cholesterol: Key facts

  • CVD is the leading cause of death in England and Wales1

  • The annual cost of managing CVD exceeds £30 billion2

  • Over 80% of premature CVD is avoidable2,3

  • Reducing CVD risk by 1% over 10 years would prevent 25,000 new cases of CVD4

  • Reducing total cholesterol levels by 5% would save the NHS £80 million per annum4

  • LDL-C is a key modifiable CVD risk factor1

  • NICE targets for secondary prevention of CVD (high risk patients): TC < 4 mmol/L or LDL-C < 2 mmol/L1

  • More than 50% of patients will not achieve their target lipid levels on statin therapy alone1

1. NICE Clinical Guideline 67. May 2008. Reissued March 2010, 2. British Heart Foundation. Modelling the UK burden of cardiovascular disease to 2020. September 2008. Available at: http://www.bhf.org.uk/plugins/PublicationsSearchResults/DownloadFile.aspx?docid=ad18e5a0-7da6-4c7c-8142-f68f27cde451 [Accessed on 21 January 2014], 3. WHO. Cardiovascular diseases. Available at: http://www.euro.who.int/en/what-we-do/health-topics/noncommunicable-diseases/cardiovascular-diseases/facts-and-figures [Accessed on 21 January 2014], 4. Barton P et al. BMJ 2011 Jul 28; 343:d4044.


Identifying higher risk patients

Identifying ‘higher risk’ patients

Who are the higher risk patients?

  • There is a population of patients who are difficult to treat and at increased risk of CVD:

    • Patients with Type 2 diabetes and established CVD who need to achieve a total cholesterol or an LDL-C of < 4mmol/L and < 2mmol/L, respectively2,3

    • Those with familial hypercholesterolaemia requiring > 50% reduction in LDL-C4

1. Trusler D. BMJ 2011; 343: d4350, 2. NICE Clinical Guideline 67. May 2008. Reissued March 2010, Reproduced with permission 3. NICE Clinical Guideline 87. May 2009. Reproduced with permission 4. NICE Clinical Guideline 71 August 2008. Reproduced with permission.


Why treat high risk patients

Why treat high risk patients?

  • Patients with T2DM die from complications of their disease

  • > 70% of patients with T2DM die from cardiovascular causes1

  • Patients at high risk of cardiovascular disease have the most to gain from risk factor modification2

  • Intensive LDL-C reduction results in significant reductions in cardiovascular morbidity and mortality3

  • A 1 mmol/L reduction in LDL-C results in a 22% reduction in the risk of major vascular events4

  • The opportunity to improve cardiovascular outcomes by treating atherogenicdyslipidaemia in diabetes (or diabetic patients) should not be missed3

1. Laakso M. Diabetes Care 2010; 33(2): 442–449, 2. SIGN97. Feb 2007 Available at: http://www.sign.ac.uk/pdf/sign97.pdf [Accessed on 22 January 2014], 3. Nesto RW. Clinical Diabetes 2008; 26(1): 8–13, 4. Cholesterol Treatment Trialists’ (CTT) Collaboration. The Lancet 2010; 376(9753): 1670–1681.


The impact of lowering ldl c lower is better however you achieve it

The impact of lowering LDL-C: Lower is better – however you achieve it

  • For every 1 mmol/L reduction in LDL-C there is a 22% reduction in the risk of major vascular events at 1 year1

  • There is a proportional relationship between lowering LDL-C and reducing 5-year non-fatal MI and CHD death risk – irrespective of how LDL-C is lowered2

1 mmol/L

22%

1. Cholesterol Treatment Trialists’ (CTT) Collaboration. The Lancet 2010; 376(9753): 1670–1681, 2. Robinson JG et al. J Am CollCardiol2005; 46(10): 1855–1862.


Beneficial cv risk reduction with lowering ldl c however you achieve it

Beneficial CV risk reduction with lowering LDL-C – however you achieve it

Meta-analysis of data from 19 trials with 81,859 participants1

100

80

60

40

20

0

-20

Oslo

MRC

Los Angeles

Upjohn

LRC

NHLBI

POSCH

4S

WOSCOPS

CARE

LIPID

AF/TexCAPS

HPS

ALERT

PROSPER

ASCOT-LLA

CARDS

The London and Sydney trials are not shown, but were included in the analysis

Nonfatal myocardial infarction and CHD death

Estimated relative risk reduction (%)

Relative risk reduction

95% probability interval

Slope=1

15

20

25

30

35

40

LDL-C reduction (%)

Adapted from Robinson JG et al. J Am CollCardiol2005;46(10):1855–1862

  • Data from 5 diet, 3 bile acid sequestrant and 10 statin trials

  • Data from 1 surgery trial

1. Robinson JG et al. J Am CollCardiol2005; 46(10): 1855–1862.


What does nice advise for high risk patients

NICE Recommended Levels:

LDL-C: 2.0 mmol/L

or

TC: 4.0 mmol/L

What does NICE advise for high risk patients?

*MHRA (May 2010) reported increased risk of myopathy with high-dose (80 mg) simvastatin and advised: “Consider only in patients with severe hypercholesterolaemia and high risk of cardiovascular complications who have not achieved their treatment goals on lower doses, when the benefits are expected to outweigh the potential risks.”4

Note: A beneficial effect of EZETROL on cardiovascular morbidity and mortality has not yet been demonstrated

  • What guidance is available for lowering cholesterol?

    • Diabetes NICE CG871, FH NICE CG712, Lipids NICE CG673

  • Which of these guidelines relate to high risk patients?

    • Diabetes NICE CG87

      • Initiate simvastatin 40 mg, increasing to 80 mg* unlessTC < 4mmol/L or LDL-C < 2mmol/L

      • Consider intensifying therapy with statin or ezetimibe if existing or new CVD or increased albumin excretion rate

    • FH NICE CG71

      • High intensity statin to achieve a recommended LDL-C reduction of 50% from baseline. Ezetimibe co-administered with a statin (if) target lipid levels are not controlled after dose titration of initial statin, or because titration is limited by intolerance to initial statin

1. NICE Clinical Guideline 87. May 2009. Reproduced with permission. 2. NICE Clinical Guideline 71. August 2008 Reproduced with permission. 3. NICE Clinical Guideline 67. May 2008. Reissued March 2010. Reproduced with permission. 4. MHRA. Drug Safety Update. May 2010. Available at: http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON085169 [Accessed on 21 January 2014].


What are your options

What are your options?

Lifestyle

Statin

Fibrate

Resin, fish oil, nicotinic acid*

Cholesterol absorption inhibitor

*No longer available as a modified release medicine in the EU. Instant release available as a supplement in health shops.


Treatment options

Treatment options

What the trials say


Ldl cholesterol lower is better

LDL-C lowering efficacy of lipid lowering therapies

All reductions are from baseline as specified in the relevant studies.

*MHRA (May 2010) reported increased risk of myopathy with high-dose (80 mg) simvastatin and advised: “Consider only in patients with severe hypercholesterolaemia and high risk of cardiovascular complications who have not achieved their treatment goals on lower doses, when the benefits are expected to outweigh the potential risks.”4

1. Law MR et al. BMJ 2003; 326(7404); 1423–1427, 2. Crestor Summary of Product Characteristics, 3. Jones PH et al. Am J Cardiol2003; 93: 152–160, 4. Zocor Summary of Product Characteristics, 5. Lipostat Summary of Product Characteristics, 6. Shepherd J et al. The Lancet 2002; 360(9346): 1623–1630, 7. Conard SE et al. Am J Cardiol2008; 102: 1489–1494, 8. Leiter LA et al. Am J Cardiol2008; 102(11): 1495–1501, 9.Goldberg AC et al. Mayo ClinProc. 2004; 79: 620–629, 10.Knapp HH et al. Am J Med 2001; 110(5): 352–360.


Lowering ldl c treatment options

Lowering LDL-C: Treatment options

6%1,2

8%1

23.2%1

  • 1. NICE Technology Appraisal Guidance 132, November 2007, 2. Knopp RH. N Engl J Med 1999; 341: 498–511.


Lowering ldl c treatment options1

Lowering LDL-C: Treatment options

5

0

-5

-10

-15

-20

-25

Treatment option

  • % LDL-C reduction from treated baseline

Treated baseline

Doubling statin

Switching statin

Adding ezetimibe

6%1,2

8%1

23.2%1

% LDL-C reduction from baseline

Graphical version of previous slide

  • 1. NICE Technology Appraisal Guidance 132, November 2007, 2. Knopp RH. N Engl J Med 1999; 341: 498–511.


Treating high risk patients what are your choices

Treating high-risk patients: What are your choices?

*MHRA (May 2010) reported increased risk of myopathy with high-dose (80 mg) simvastatin and advised: “Consider only in patients with severe hypercholesterolaemia and high risk of cardiovascular complications who have not achieved their treatment goals on lower doses, when the benefits are expected to outweigh the potential risks.”4

Note: A beneficial effect of EZETROL on cardiovascular morbidity and mortality has not yet been demonstrated

1. NICE Clinical Guideline 67. May 2008. Reissued March 2010, 2. NICE Clinical Guideline 87. May 2009 , 3. NICE Clinical Guideline 71. August 2008, 4.MHRA. Drug Safety Update. May 2010. Available at: http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON085169 [Accessed on 21 January 2013].


Nice recommendations for treatment with ezetimibe 1

NICE recommendations for treatment with ezetimibe1

“The Committee agreed that there is sufficient evidence to link reductions in LDL cholesterol concentrations induced by treatment with ezetimibe with future reductions in cardiovascular events.”* 1

*Note: A beneficial effect of EZETROL on cardiovascular morbidity and mortality has not yet been demonstrated

  • Ezetimibe is recommended, as an option, in combination with a statin, when:

    • Serum total or LDL-C concentration is not appropriately controlled

      • either after appropriate dose titration of initial statin or

      • because dose titration is limited by intolerance to the initial statin therapy

    • You are considering switching from the initial statin therapy

  • Ezetimibemonotherapy is recommended, as an option, in adults with primary hypercholesterolaemia

    • who are intolerant to statins, or who are contraindicated for statin therapy

1. NICE Technology Appraisal Guidance 132. November 2007. Reproduced with permission.


Safety data for ezetimibe 1

Safety data for ezetimibe1

ALT, alanineaminotransferase; AST, aspartateaminotransferase; CPK, creatinephosphokinase; GGT, gamma-glutamyltransferase

Importantly, evidence from 13 randomised, blinded clinical trials in which ezetimibe and simvastatin were administered in combination either as separate or combined tablets (n=4,558) suggests that ezetimibe does not enhance nor aggravate the known muscle effects of simvastatin when compared to simvastatinmonotherapy (n=2,563).2

1. Ezetrol 10 mg Tablets Summary of Product Characteristics, 2. Davidson MH et al. Am J Cardiol2006; 97(2): 223–228.


What nice says patients with type 2 diabetes

What NICE says… Patients with Type 2 Diabetes

“Consider intensifying cholesterol-lowering therapy (with a more effective statin or ezetimibe in line with NICE guidance) if there is existing or newly diagnosed cardiovascular disease, or if there is an increased albumin excretion rate, to achieve a total cholesterol level below 4.0 mmol/litre (and HDL cholesterol not exceeding 1.4 mmol/litre) or an LDL cholesterol level below 2.0 mmol/litre.”

National Institute for Health and Care Excellence. Type 2 Diabetes. Clinical Guideline 87 July 2011. London:NICE. Available from http://guidance.nice.org.uk/CG87. Reproduced with permission


What nice says patients with familial hypercholesterolaemia

What NICE says…Patients with Familial Hypercholesterolaemia

  • “Ezetimibe, co-administered with initial statin therapy, is recommended as an option for the treatment of adults with heterozygous-familial hypercholesterolaemia who have been initiated on statin therapy when:

  • Serum total or LDL-C concentration is not appropriately controlled either after appropriate dose titration of initial statin therapy or because dose titration is limited by intolerance to the initial statin therapy;

  • and

  • Consideration is being given to changing from initial statin therapy to an alternative statin.”

National Institute for Health and Care Excellence. FH. Clinical Guideline 71 August 2008. London: NICE. Available from http://guidance.nice.org.uk/CG71. Reproduced with permission


In summary treating higher risk patients

In summary: Treating higher risk patients

*Note: A beneficial effect of EZETROL on cardiovascular morbidity and mortality has not yet been demonstrated

  • In secondary prevention patients NICE recommends to consider increasing the statin to simvastatin 80mg, or a drug of similar efficacy and acquisition cost, if TC <4mmol/L or LDL-C<2mmol/L is not attained1

  • The evidence indicates that a greater reduction in baseline LDL-C can be achieved by adding ezetimibe to a statin, than by increasing the statin dose,2 or by switching from simvastatin to atorvastatin3

  • In patients with CVD, NICE recommends intensified treatment for hypercholesterolaemia.1 In these patients, ezetimibe added to a statin can help more patients achieve NICE-recommended lipid management levels

  • Reduction in LDL-C, irrespective of how it is achieved, reduces the risk of CVD.4 NICE have accepted there is sufficient evidence to link LDL-C reduction via ezetimibe use with a reduction in future CV events*5

1. NICE Clinical Guideline 67. May 2008. Reissued March 2010. Reproduced with permission. 2. Conard SE et al. Am J Cardiol2008; 102(11): 1489–1494, 3. McCormack T et al. Int J ClinPrac2010; 64(8): 1052–1061, 4. Robinson JG, etal. J Am CollCardiol2005; 46(10): 1855–1862, 5. NICE Technology Appraisal Guidance 132, November 2007. Reproduced with permission.


Additional slides

Additional Slides


Leiter la et al

Leiter LA et al.

Efficacy and safety of ezetimibe added on to atorvastatin (40 mg) compared with up-titration of atorvastatin (to 80 mg) in hypercholesterolemic patients at high risk of coronary heart disease. Am J Cardiol2008; 102 (11): 1495–1501.


Efficacy of adding ezetimibe to atorvastatin 40mg vs up titrating to atorvastatin 80mg

Efficacy of adding ezetimibe to atorvastatin 40mg vs. up-titrating to atorvastatin 80mg

Randomised, multi-centre, double-blind study

Criteria – hypercholesterolaemia and high risk of CHD

LDL-C ≥1.8mmol/L and ≤4.1mmol/L

Run-in – atorvastatin 40mg for at least 4 weeks

Treatment – up-titration to atorvastatin 80mg or addition of ezetimibe10mg to atorvastatin 40mg for 6 weeks

Leiter LA et al. Efficacy and Safety of Ezetimibe Added on to Atorvastatin (40mg) Compared with Uptitration of Atorvastatin (to 80mg) in Hypercholesterolemic Patients at High Risk of Coronary Heart Disease Am J Cardiol 2008; 102: 1495–1501.


Efficacy of adding ezetimibe to atorvastatin 40mg vs up titrating to atorvastatin 80mg1

Efficacy of adding ezetimibe to atorvastatin 40mg vs. up-titrating to atorvastatin 80mg

0

-5

-10

-15

-20

-25

-30

Baseline

Atorvastatin 80mg (n=279)

Atorvastatin/ezetimibe 40/10mg (n=277)

Baseline LDL-C 2.3mmol/L

p<0.001 for treatment difference between arms

-11%

% change in LDL-C from treated baseline at week 6

Note: A beneficial effect of EZETROL on cardiovascular morbidity and mortality has not yet been demonstrated

-27%

Leiter LA et al. Am J Cardiol2008; 102: 1495–1501.


Tolerability of adding ezetimibe to atorvastatin 40mg vs up titrating to atorvastatin 80mg

Tolerability of adding ezetimibe to atorvastatin 40mg vs. up-titrating to atorvastatin 80mg

  • Tolerability profiles of both treatments generally similar and consistent with previous studies of similar duration

  • Serious adverse event incidence low

    • None considered drug-related

  • No myopathy or rhabdomyolysis

  • No significant differences in pre-specified AEs between groups

Leiter LA et al. Am J Cardiol2008; 102: 1495–1501.


Jones ph et al

Jones PH et al.

STELLAR Study Group. Comparison of the efficacy and safety of rosuvastatin versus atorvastatin, simvastatin and pravastatin across doses. Am J cardiol2003; 93: 152–160.


Ldl cholesterol lower is better

Comparison of the efficacy and safety of rosuvastatin vs. atorvastatin, simvastatin and pravastatin across doses (STELLAR trial)1

* Rosuvastatin 80 mg is not licensed

† MHRA (May 2010) reported increased risk of myopathy with high-dose (80 mg) simvastatin and advised: “Consider only in patients with severe hypercholesterolaemia and high risk of cardiovascular complications who have not achieved their treatment goals on lower doses, when the benefits are expected to outweigh the potential risks.”2

  • Randomised, multi-centre, parallel group, open-label (n = 2431)

  • Patient criteria – hypercholesterolaemia i.e. LDL-C between  4.10 and < 6.42 mmol/l ( 160 and < 250 mg/dl)

  • Treatment duration – 6 weeks

  • Randomised treatments:

    • rosuvastatin 10, 20, 40 or 80 mg*

    • atorvastatin 10, 20, 40 or 80 mg

    • simvastatin 10, 20, 40 or 80 mg†

    • pravastatin 10, 20, or 40 mg

1. Jones PH et al. Am J Cardiol2003; 93: 152–160, 2. MHRA. Drug Safety Update. May 2010. Available at: http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON085169 [Accessed on 21 January 2014].


Ldl cholesterol lower is better

Pooled-dose analyses: rosuvastatin reduced mean LDL-C at 6 weeks more than atorvastatin, simvastatin and pravastatin

0

-5

-10

-15

-20

-25

-30

Baseline

Reduction compared with atorvastatin 10–80 mg

Reduction compared with simvastatin 10 to 80 mg

Reduction compared with pravastatin 10 to 40 mg

-8.2%

p <0.001 (for all 3 comparisons)

Increased mean % reductions in LDL-C from baseline at Week 6 with rosuvastatin vs. comparator statins

-12 to -18%

-26%

Adapted from Jones PH et al. Am J Cardiol2003; 93: 152–160


Safety rosuvastatin vs atorvastatin simvastatin and pravastatin

Safety: rosuvastatin vs. atorvastatin, simvastatin and pravastatin

  • Drug tolerability was similar across treatments

  • Percentage of patients reporting AEs ranged from 40 – 56% across treatments; most mild to moderate in intensity and dose-related

  • Most common AEs: pain (6%), pharyngitis (5%), myalgia (4%), headache (4%)

  • 29 serious adverse events reported

  • 2 patients died (1 received simvastatin 10 mg, 1 atorvastatin 40 mg); both deaths due to CV disease – unrelated to treatment

Jones PH et al. Am J Cardiol2003; 93: 152–160


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