Lipid Management Strategies: Combination Therapy

Primary preventive measures for cardiovascular disease are centered on lifestyle changes such as diet, exercise, and weight management. If these lifestyle changes do not prove adequate in optimizing lipid levels, drug treatment should be considered. Four classes of lipid-lowering agents are presented briefly, including their respective lipoprotein effects, contraindications, and common adverse effects These agents include 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins), nicotinic acid, fibric acid derivatives, and bile acid sequestrants. An investigational class of agents, cholesterol absorption inhibitors, is mentioned. Four of the 5 landmark monotherapy statin clinical trials reviewed for achievement of low-density lipoprotein cholesterol (LDL-C) levels did not reach new guideline levels of <100 mg/dL nor did they reach older LDL-C goals. The use of starting doses and the nonlinear dose-response curve of statins may be responsible for this finding. Results of a clinical study evaluating the combination of a statin and colesevelam (a bile acid sequestrant) demonstrated a more pronounced reduction in LDL-C, total cholesterol, and triglycerides as well as an improved increase in high-density lipoprotein cholesterol with combination therapy as compared to monotherapy. To achieve new LDL-C goals, clinicians should use more aggressive treatment strategies, including combination therapy. (Advanced Studies in Medicine 2002;2(11):402-408)