dr.lefi lunch sympo.pdf

8/18/2019 dr.lefi lunch sympo.pdf

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Dr Achmad Lefi SpJP (K)


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LDL-C is the primary target of lipid-lowering therapy -All ATP reports have identified LDL-C as the primarytarget

Intensity of LDL-C lowering should be adjusted to theindividual’s absolute risk of CHDLDL-C lowering with standard statin regimens reducesthe risk of CV events in a wide range of individuals.

Further reduction in LDL-C with more intensiveregimens produce further reductions in the incidenceof CV events

NCEP, Adult Treatment Panel III. JAMA . 2001;285:2486-2497


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LDL-C achieved mg/dL (mmol/L)

CARE - Placebo

0

25

30

40(1.0)

60(1.6)

80(2.1)

100(2.6)

120(3.1)

140(3.6)

160(4.1)

180(4.7)

4S - Rx

LIPID - Placebo

LIPID - Rx

HPS - Rx

WOSCOPS – Placebo

WOSCOPS - Rx

AFCAPS - Placebo

ASCOT - Placebo AFCAPS - Rx

ASCOT - Rx

4S - Placebo

Rx - Statin therapyPRA – pravastatinATV - atorvastatin

20

10

5

15

200(5.2)

CARE - Rx

PROVE-IT - PRA

PROVE-IT – ATV

1.Rosenson RS. Exp Opin Emerg Drugs .2004; 9(2):269-279

2.LaRosa JC et al. N Engl J Med .2005; 352 :1425-1435

TNT – ATV10

TNT – ATV80

Secondary PreventionPrimary Prevention

HPS - Placebo


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P r o p o r t

i o n a

l r e

d u c t

i o n

i n e v e n

t r a

t e ( S E )

50%

40%

30%

20%

10%

0%

-10%

0.5 1.0 1.5 2.0

Reduction in LDL cholesterol (mmol/L)

21%

Major Vascular Events

Relation between proportional reduction in incidence of majorcoronary events and major vascular events and mean absoluteLDL-C reduction at 1 year

Lan cet 2005; 366: 1267-78


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Hsia J et al. Cardiology 2011;57:1666-1675


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Very-high-risk pts a

1988ATP I

1993ATP II

2001ATP III

2004ATP III Update

20062° AHA/ACC

2011ESC/EAS

Optional goal:

<

70

mg/L 4Reasonable goal:

<

70

mg/dL 5


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Lipid guidelines in the US, Canada and Europe

Year 2004 2009 2011Guideline NCEP ATP III

Guidelines 1Canadian CV

Society 2ESC/EAS

Guidelines 3

LDL-C < 100 mg/dL(< 2.6 mmol/L)

< 70 mg/dL

(< 1.8mmol/L)reasonable for

high risk patients

< 80 mg/dL(< 2 mmol/L)

or ≥ 50%

decrease in LDL-C

< 70 mg/dL(< 1.8 mmol/L)

and/or ≥ 50%

LDL-C reduction

1. Grundy S. et al. Circulation 2004; 110: 227-39

2. Genest J. et al. Can J Cardiol 2009;25:567-579 3. Eur Heart J 2011; 32: 1769-1818

High-Risk or Very High-Risk Patients


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ESC / EAS GuidelinesRecommendations for treatment targets for LDL-C

Patients LDL-C goalVery high CV risk

- established CVD < 1.8 mmol/L- diabetes with target organ damage (70 mg/dL)- type 2 diabetes > 40 y, with 1 other CVD risk factor and/or - moderate to severe CKD 50% LDL-C- SCORE level 10% reduction

High CV risk- markedly elevated single risk factors < 2.5 mmol/L

- all other type 2 diabetes (100 mg/dL)- SCORE level 5-10%

Moderate risk- SCORE level > 1 to 5% < 3.0 mmol/L

(115 mg/dL)

Eur Heart J 2011: 32: 1769-1818


9/30Stone NJ, et al. 2013 ACC/AHA Blood Cholesterol Guideline


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Stone NJ, et al. 2013 ACC/AHA Blood Cholesterol Guideline


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“Clinicians treating high-risk patients who have a less-than-anticipated response to statins, who are unable to tolerate a less-than-recommended intensity of a statin, or who are completelystatin intolerant may consider the addition of a nonstatincholesterol-lowering therapy . High-risk individuals includethose with ASCVD, those with LDL –C ≥190 mg/ dL and individualswith diabetes .”

“In this situation, this guideline recommends clinicians

preferentially prescribe drugs that have been shown in RCTs toprovide ASCVD risk-reduction benefits that outweigh the potentialfor adverse effects drug-drug interaction, and patient preferences .”

Stone NJ, et al. 2013 ACC/AHA Blood Cholesterol Guideline


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IMP R OV E I TA Multicenter, Double-Blind, Randomized

Study to Establish the Clinical Benefit andSafety of Vytorin (Ezetimibe/SimvastatinTablet) vs Simvastatin Monotherapy in High-Risk Subjects PresentingWith Acute Coronary Syndrome


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Patients stabilized post ACS ≤ 10 days:LDL-C 50 – 125*mg/dL (or 50 – 100**mg/dL if prior lipid-lowering Rx)

Standard Medical & Interventional Therapy

Ezetimibe / Simvastatin10 / 40 mg

Simvastatin40 mg

Follow-up Visit Day 30, every 4 months

Duration: Minimum 2 ½-year follow-up (at least 5250 events)

Primary Endpoint: CV death, MI, hospital admission for UA,coronary revascularization (≥ 30 days after randomization), or stroke

N=18,144

Uptitrated to

Simva 80 mgif LDL-C > 79(adapted per

FDA label 2011)

*3.2mM**2.6mM

Cannon CP AHJ 2008;156:826-32; Califf RM NEJM 2009;361:712-7; Blazing MA AHJ 2014;168:205-12

90% power to detect~9% difference


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IMPROVE-IT: First large trial evaluating clinicalefficacy of combination EZ/Simva vs. simvastatin(i.e., the addition of ezetimibe to statin therapy):

Does lowering LDL-C with the non-statin agentezetimibe reduce cardiac events?

Is (Even) Lower (Even) Better?

(estimated mean LDL-C ~50 vs. 65mg/dL)Safety of ezetimibe

Cannon CP AHJ 2008;156:826-32; Califf RM NEJM 2009;361:712-7; Blazing MA AHJ 2014;168:205-12


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Simva — 34.7%2742 events

EZ/Simva — 32.7%2572 events

HR 0.936 CI (0.887, 0.988)

p=0.016

Cardiovascular death, MI, documented unstable angina requiringrehospitalization, coronary revascularization (≥30 days), or stroke

7-year event rates

NNT= 50


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Lymphatic Vessel

Apo B 48

ACAT

CE PoorChylomicron

NPC1L1Protein

ABCG5/G8

Intestinal Lumen

Enterocyte

XLess free

cholesterol & sterol

absorption

EZETIMIBE

Ezetimibe has specific, high affinity binding to astructural protein on the brush border

Ezetimibe : Mechanism of Action


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-60%

-40%

-20%

0%

20%

40%

60%

80%

100%

120%

Cholesterol absortion

Cholesterol production

Miettinen Gylling. Eur J clin invest 2003;33:976-9

+ 103%p,


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-80%

-60%

-40%

-20%

0%

20%

40%

60%

80%

100%

Cholesterol absortion

Cholesterol production

Sudho T et all: circulation.2002 106 1943-19

+ 89%

p,


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Bridging the Gap Through ComplementaryMechanisms of Action

DIETARYCHOLESTEROL

BILIARY SECRETION

INTESTINE

Excretion

VLDL LDL

Absorption

synthesis

IDL

Ezetimibe

CholesterolAbsorptionInhibition

Statins


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Effects of statins on HDL-C and LDL-C : resultsfrom the VOYAGER database (32 258 patients)

Nicholls et al. Am J Cardiol 2010;105 :69-76

% change in LDL-C and HDL-C levels

Dose LDL-C HDL-C

(mg) n LSM % change n LSM % changefrom baseline from baseline

Rosuvastatin 5 668 -38.8 670 5.510 11650 -44.1 11690 6.120 3551 -49.5 3554 7.040 2981 -54.7 2993 7.9

Atorvastatin 10 7804 -35.5 7837 4.520 3896 -41.4 3908 3.5

40 1324 -46.2 1324 2.480 2070 -50.2 2072 2.3

Simvastatin 10 165 -27.4 165 4.220 2923 -33.0 2929 5.040 542 -38.9 548 5.0

80 478 -45.0 479 5.3

5.3

5.4

5.2

5.9

4.8

4.0

5.6

5.9

6.1


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10

20

30

40

50

60

Add Ezetrol

Titrasi Statin

6 %

6 %

6 %

21 %

Incremental Reduction: One Step or Three Steps?

THREE-STEP TITRATION

ONE-STEP COADMINISTRATION

% R e d u c t i o n i n L D L C

h o l e s t e r o

l

Gagne, Bays HE, Welss SR et al. For the Ezetimibe study grup. Efficacy and safety of Ezetimibe Added to ongoing statin therapy for treatment of patients with primary hypercholesterolemia. AM. J. Cardiol. 2002; 90. 1084-1091


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-27%

-17% -18%

0%

-12%-11%

-7%-8%

-1%

-6%

-30

-25

-20

-15-10

-5

0

510

M

e a n C

h a n g e F r o m

S t a t i n - T

r e a t e d

B a s e l i n e , %

EZETROL added to atorvastatin 40 mg (n=277Atorvastatin 40 mg titrated to 80 mg (n=279)

LDL-C Total-C ApoB HDL-C TGa

P


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74%

32%

0%

20%

40%

60%

80%

100%

P a t i e n t s A c h i e v i n g

L D L - C G o a l

EZETROL added to atorvastatin 40 mg mean on-statin baseline LDL-C=89 mg/dL)

Atorvastatin 40 mg titrated to 80 mg (mean on-statin baseline LDL-C=89 mg/dL)

(n=277) (n=279)

P


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-37

-53*

-42

-54*

-45

-56*-54

-61*

-70

-60

-50

-40

-30

-20

-10

0

M e a n % c h a n g e i n c a

l c u

l a t e

d L D L - C

f r o m

b a s e

l i n e a t 1 2 w e e

k s

Ezetimibe

+atorvastatin10 mg(n=65)

Atorvastatin10 mg(n=60)

Ezetimibe



Ezetimibe



Ezetimibe



*p


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Patients:618 hypercholesterolemic patients with high cardiovascular riskMen and women ≥18 and


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-28%

-18%

-23%

-18%

2%

-11

-17%

-10%

-14%

-10%

3%

-5

-30

-25

-20

-15

-10

-5

0

5

10

M e a n C h a n g e F r o m

T r e a t e

d B a s e l i n e , %

VYTORIN 10/20 mg (n=301 –305) Rosuvastatin 10 mg (n=292 –297)

LDL-C TCNon –

HDL-C Apo B

HDL-C

TG a

P ≤0.001

P= NS

P ≤0.001

P ≤0.001

P ≤0.001

P= NS

VYTORIN as an adjunct to diet when diet and exercise alone are not enough

Mean Treated Baseline LDL-C = 124 mg/dL Mean Treated Baseline LDL-C = 125 mg/dL

The clinical impact of comparative differences in lipid changes between products is not known.The independent effect of raising HDL-C or lowering TG on the risk of coronary and cardiovascular morbidity and mortality has not been determined.aMedian change from treated baseline.

Total-C = total cholesterol; ApoB = apolipoprotein B; TG = triglycerides.1. FarnierM et al. IntJ Clin Pract . 2009;63:547 –559.


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73%

56%

0%

20%

40%

60%

80%100%


L D L - C < 1 0 0 m g

/ d L , %

VYTORIN 10/20 mg (n=301 –305)

Rosuvastatin 10 mg (n=292 –297)

25%

11%

0%

20%

40%

60%

80%

100%


L D L - C < 7 0 m g

/ d L , %

VYTORIN 10/20 mg (n=301 –305)

Rosuvastatin 10 mg (n=292 –297)

Mean Treated Baseline LDL-C = 124 mg/dL




1. Farnier M et al.Int J Clin Pract . 2009;63:547 –559.


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Eze timibe + Low Dose Statin = High DoseStatin Efficacy

-48.5%- 44.8%

-32.7%

– 70

– 60

– 50

– 40

– 30

– 20

– 10

0

M e a n

L D L - C

C h a n g e

F r o m

B a s e

l i n e

%

Sim10

mgEze

Sim

1 0Sim80mg

EZETROL+Simva 10mg

Bays,et.al, Clin Ther, 2004 Vol 26 No 11

– 70

– 60

– 50

– 40

– 30

– 20

– 10

0

M e a n

L D L - C

C h a n g e

F r o m

B a s e

l i n e

%

Ator 10

mg Eze+

Ator 10

Ator 80mg

-35%

-51% - 50%

EZETROL+Ator 10mg

Ballantyne, et.al, Circulation May 2003

-44.9%

Kosoglu, et.al, Curr Med Res & Opin 2004, Vol 20 No.8

- 61.4%-55%

– 70

– 60

– 50

– 40

– 30

– 20

– 10

0

M e a n

L D L - C

C h a n g e

F r o m

B a s e

l i n e

%

Ros

10mg Eze+

Ros10

EZETROL+Rosu 10mg

Ros40mg


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LDL-c is the primary target for lipid loweringtherapyIMPROVE-IT is the first non-statin trial thatshows a clinical benefit in reducing

cardiovascular outcome ( 6.4%) by lowering LDLup to 53.7 mg/dLCombination therapy simultaneously inhibitboth cholesterol biosynthesis and intestinalcholesterol absorption, represents an effectivecholesterol-lowering intervention and will helppatient to achieve their target goal


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