Modern intervention strategies for managing dyslipidaemia: the case for combination therapy

Abstract

steady decline in cardiovascular mortality has occurred in recent decades, but a substantial burden of cardiovascular mortality remains. Intervention with statins, for example, has resulted in significant reductions in cardiovascular event rates in a broad range of patient populations, but these agents reduce cardiovascular event rates by only about 20—40%, despite profound reductions in low-density lipoprotein cholesterol (LDL-C) in some trials. Low high-density lipoprotein cholesterol (HDL-C) is a risk factor for adverse cardiovascular outcomes independent of levels of LDL-C. Well designed intervention trials have demonstrated marked improvements in cardiovascular outcomes with agents that raise levels of HDL-C. Combinations of statins with nicotinic acid, the most potent agent for increasing levels of HDL-C currently available, appear to be the most effective strategy for managing cardiovascular risk. Indeed, reductions in the risk of cardiovascular events of up to 90% relative to placebo with a nicotinic acid-statin combination were observed in the double-blind, randomised HDL Atherosclerosis Treatment Study (HATS). A once-daily, prolonged-release formulation of nicotinic acid, Niaspan® is as effective as immediate-release nicotinic acid with superior tolerability and safety. A randomised, double-blind placebo-controlled evaluation of Niaspan® added to a statin, the Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol (ARBITER 2) study, demonstrated significant inhibition of atherosclerosis in men with low HDL-C over only one year of treatment. Patients with low HDL-C are at elevated cardiovascular risk and combination treatment with nicotinic acid and a statin represents a rational and evidence-based treatment for this population.