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Gupta KK, Ali S, Sanghera RS. Pharmacological Options in Atherosclerosis: A Review of the Existing Evidence. Cardiol Ther 2018; 8:5-20. [PMID: 30543029 PMCID: PMC6525235 DOI: 10.1007/s40119-018-0123-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Indexed: 12/11/2022] Open
Abstract
Coronary heart disease (CHD) is the leading cause of mortality worldwide and high low-density lipoprotein (LDL) cholesterol levels have been shown to be key in the pathogenesis of this condition. Lipid control has therefore been the subject of decades of research and has led to many large and robust randomized controlled trials, as well as the highest grossing drug of all time—Lipitor (atorvastatin). Statin therapy has long been indicated for secondary and more recently primary prevention. However, despite the large-scale use of statins, CHD prevalence remains high, and some patients do not respond to statin therapy. There has been a large push to find and test alternative lipid-lowering agents, these include fibrates, cholesterol absorption inhibitors, and proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitors. It is the aim of this review to assess the literature surrounding each of these groups of drugs.
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Affiliation(s)
| | - Shair Ali
- St George's Hospital NHS Trust, London, UK
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2
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Zhan S, Tang M, Liu F, Xia P, Shu M, Wu X. Ezetimibe for the prevention of cardiovascular disease and all-cause mortality events. Cochrane Database Syst Rev 2018; 11:CD012502. [PMID: 30480766 PMCID: PMC6516816 DOI: 10.1002/14651858.cd012502.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) remains an important cause of mortality and morbidity, and high levels of blood cholesterol are thought to be the major modifiable risk factors for CVD. The use of statins is the preferred treatment strategy for the prevention of CVD, but some people at high-risk for CVD are intolerant to statin therapy or unable to achieve their treatment goals with the maximal recommended doses of statin. Ezetimibe is a selective cholesterol absorption inhibitor, whether it has a positive effect on CVD events remains uncertain. Results from clinical studies are inconsistent and a thorough evaluation of its efficacy and safety for the prevention of CVD and mortality is necessary. OBJECTIVES To assess the efficacy and safety of ezetimibe for the prevention of CVD and all-cause mortality. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase and Web of Science on 27 June 2018, and two clinical trial registry platforms on 11 July 2018. We checked reference lists from primary studies and review articles for additional studies. No language restrictions were applied. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared ezetimibe versus placebo or ezetimibe plus other lipid-modifying drugs versus other lipid-modifying drugs alone in adults, with or without CVD, and which had a follow-up of at least 12 months. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, assessed risk of bias and contacted trialists to obtain missing data. We performed statistical analyses according to the Cochrane Handbook for Systematic Reviews of Interventions and used the GRADE to assess the quality of evidence. MAIN RESULTS We included 26 RCTs randomising 23,499 participants. All included studies assessed effects of ezetimibe plus other lipid-modifying drugs compared with other lipid-modifying drugs alone or plus placebo. Our findings were driven by the largest study (IMPROVE-IT), which had weights ranging from 41.5% to 98.4% in the different meta-analyses.Ezetimibe with statins probably reduces the risk of major adverse cardiovascular events compared with statins alone (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.90 to 0.98; a decrease from 284/1000 to 267/1000, 95% CI 256 to 278; 21,727 participants; 10 studies; moderate-quality evidence). Trials reporting all-cause mortality used ezetimibe with statin or fenofibrate and found they have little or no effect on this outcome (RR 0.98, 95% CI 0.91 to 1.05; 21,222 participants; 8 studies; high-quality evidence). Adding ezetimibe to statins probably reduces the risk of non-fatal myocardial infarction (MI) (RR 0.88, 95% CI 0.81 to 0.95; a decrease from 105/1000 to 92/1000, 95% CI 85 to 100; 21,145 participants; 6 studies; moderate-quality evidence) and non-fatal stroke (RR 0.83, 95% CI 0.71 to 0.97; a decrease 32/1000 to 27/1000, 95% CI 23 to 31; 21,205 participants; 6 studies; moderate-quality evidence). Trials reporting cardiovascular mortality added ezetimibe to statin or fenofibrate, probably having little or no effect on this outcome (RR 1.00, 95% CI 0.89 to 1.12; 19457 participants; 6 studies; moderate-quality evidence). The need for coronary revascularisation might be reduced by adding ezetimibe to statin (RR 0.94, 95% CI 0.89 to 0.99; a decrease from 196/1000 to 184/1000, 95% 175 to 194; 21,323 participants; 7 studies); however, no difference in coronary revascularisation rate was observed when a sensitivity analysis was limited to studies with a low risk of bias.In terms of safety, adding ezetimibe to statins may make little or no difference in the risk of hepatopathy (RR 1.14, 95% CI 0.96 to 1.35; 20,687 participants; 4 studies; low-quality evidence). It is uncertain whether ezetimibe increase or decrease the risk of myopathy (RR 1.31, 95% CI 0.72 to 2.38; 20,581 participants; 3 studies; very low-quality evidence) and rhabdomyolysis, given the wide CIs and low event rate. Little or no difference in the risk of cancer, gallbladder-related disease and discontinuation due to adverse events were observed between treatment groups. For serum lipids, adding ezetimibe to statin or fenofibrate might further reduce the low-density lipoprotein cholesterol (LDL-C), total cholesterol and triglyceride levels and likely increase the high-density lipoprotein cholesterol levels; however, substantial heterogeneity was detected in most analyses.None of the included studies reported on health-related quality of life. AUTHORS' CONCLUSIONS Moderate- to high-quality evidence suggests that ezetimibe has modest beneficial effects on the risk of CVD endpoints, primarily driven by a reduction in non-fatal MI and non-fatal stroke, but it has little or no effect on clinical fatal endpoints. The cardiovascular benefit of ezetimibe might involve the reduction of LDL-C, total cholesterol and triglycerides. There is insufficient evidence to determine whether ezetimibe increases the risk of adverse events due to the low and very low quality of the evidence. The evidence for beneficial effects was mainly obtained from individuals with established atherosclerotic cardiovascular disease (ASCVD, predominantly with acute coronary syndrome) administered ezetimibe plus statins. However, there is limited evidence regarding the role of ezetimibe in primary prevention and the effects of ezetimibe monotherapy in the prevention of CVD, and these topics thus requires further investigation.
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Affiliation(s)
- Shipeng Zhan
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Pharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Min Tang
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Pharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Fang Liu
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Pharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Peiyuan Xia
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Pharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Maoqin Shu
- First Affiliated Hospital of Third Military Medical University (Army Medical University)Cardiovascular DepartmentChongqingChina
| | - Xiaojiao Wu
- Third Military Medical University (Army Medical University)Department of Health Statistics, College of Preventive MedicineChongqingChina
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Abtan J, Bhatt DL, Elbez Y, Sorbets E, Eagle K, Reid CM, Baumgartner I, Wu D, Hanson ME, Hannachi H, Singhal PK, Steg PG, Ducrocq G. Geographic variation and risk factors for systemic and limb ischemic events in patients with symptomatic peripheral artery disease: Insights from the REACH Registry. Clin Cardiol 2017; 40:710-718. [PMID: 28520087 PMCID: PMC6490387 DOI: 10.1002/clc.22721] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/24/2017] [Accepted: 03/30/2017] [Indexed: 01/15/2023] Open
Abstract
Background Patients with symptomatic peripheral artery disease (PAD) are at high risk of ischemic events. However, data about predictors of this risk are limited. Hypothesis We analyzed baseline characteristics and 4‐year follow‐up of patients enrolled in the international REduction of Atherothrombosis for Continued Health (REACH) Registry with symptomatic PAD and no history of stroke/transient ischemic attack to describe annual rates of recurrent ischemic events globally and geographically. Methods The primary outcome was systemic ischemic events (composite of cardiovascular death, myocardial infarction, or stroke) at 4 years. The secondary outcome was limb ischemic events (composite of lower limb amputation, peripheral bypass graft, and percutaneous intervention for PAD) at 2 years. Multivariate analysis identified risk factors associated with recurrent ischemic events. Results The primary endpoint rate reached 4.7% during the first year and increased continuously (by 4%–5% each year) to 17.6% by year 4, driven mainly by cardiovascular mortality (11.1% at year 4). Japan experienced lower adjusted ischemic rates (P < 0.01) vs North America. Renal impairment (P < 0.01), congestive heart failure (P < 0.01), history of diabetes (P < 0.01), history of myocardial infarction (P = 0.01), vascular disease (single or poly, P < 0.01), and older age (P < 0.01) were associated with increased risk of systemic ischemic events, whereas statin use was associated with lower risk (P = 0.03). The limb ischemic event rate was 5.7% at 2 years. Conclusions Four‐year systemic ischemic risk in patients with PAD and no history of stroke or transient ischemic attack remains high, and was mainly driven by cardiovascular mortality.
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Affiliation(s)
- Jérémie Abtan
- FACT (French Alliance for Cardiovascular Trials), French Clinical Research Infrastructure Network, University Hospital Departments-FIRE, Hôpital Bichat, Public Assistance Hospitals of Paris, Paris Diderot University, Sorbonne University Paris Cité, and National Institute of Health and Medical Research, U-1148 Paris, France
| | - Deepak L Bhatt
- Heart and Vascular Center, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Yedid Elbez
- FACT (French Alliance for Cardiovascular Trials), French Clinical Research Infrastructure Network, University Hospital Departments-FIRE, Hôpital Bichat, Public Assistance Hospitals of Paris, Paris Diderot University, Sorbonne University Paris Cité, and National Institute of Health and Medical Research, U-1148 Paris, France
| | - Emmanuel Sorbets
- FACT (French Alliance for Cardiovascular Trials), French Clinical Research Infrastructure Network, University Hospital Departments-FIRE, Hôpital Bichat, Public Assistance Hospitals of Paris, Paris Diderot University, Sorbonne University Paris Cité, and National Institute of Health and Medical Research, U-1148 Paris, France.,Avicenne Hospital Hôpital, Public Assistance Hospitals of Paris, Paris, France
| | - Kim Eagle
- Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Christopher M Reid
- Monash University, Clayton, Victoria, Australia and Curtin University, Bentley, Perth, Western Australia
| | | | - David Wu
- Merck & Co., Inc., Kenilworth, New Jersey
| | | | | | | | - Philippe Gabriel Steg
- FACT (French Alliance for Cardiovascular Trials), French Clinical Research Infrastructure Network, University Hospital Departments-FIRE, Hôpital Bichat, Public Assistance Hospitals of Paris, Paris Diderot University, Sorbonne University Paris Cité, and National Institute of Health and Medical Research, U-1148 Paris, France.,National Heart and Lung Institute, Imperial College School of Medicine, Royal Brompton Hospital, Imperial College, London, United Kingdom
| | - Gregory Ducrocq
- FACT (French Alliance for Cardiovascular Trials), French Clinical Research Infrastructure Network, University Hospital Departments-FIRE, Hôpital Bichat, Public Assistance Hospitals of Paris, Paris Diderot University, Sorbonne University Paris Cité, and National Institute of Health and Medical Research, U-1148 Paris, France
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Sukhovershin RA, Toledano Furman NE, Tasciotti E, Trachtenberg BH. Local Inhibition of Macrophage and Smooth Muscle Cell Proliferation to Suppress Plaque Progression. Methodist Debakey Cardiovasc J 2017; 12:141-145. [PMID: 27826367 DOI: 10.14797/mdcj-12-3-141] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Atherosclerosis is a complex process responsible for a major burden of cardiovascular morbidity and mortality. Macrophages and smooth muscle cells (SMCs) are abundant within atherosclerotic plaques. This review discusses the role of macrophages and SMCs in plaque progression and provides an overview of nanoparticle-based approaches and other current methods for local targeting of atherosclerotic plaques.
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Affiliation(s)
| | | | | | - Barry H Trachtenberg
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
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5
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Smith BA, Wright C, Davidson M. Role of Ezetimibe in Lipid-Lowering and Cardiovascular Disease Prevention. Curr Atheroscler Rep 2015; 17:72. [DOI: 10.1007/s11883-015-0550-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Sugiyama S, Jinnouchi H, Hieshima K, Kurinami N, Suzuki T, Miyamoto F, Kajiwara K, Matsui K, Jinnouchi T. A pilot study of ezetimibe vs. atorvastatin for improving peripheral microvascular endothelial function in stable patients with type 2 diabetes mellitus. Lipids Health Dis 2015; 14:37. [PMID: 25903215 PMCID: PMC4417230 DOI: 10.1186/s12944-015-0028-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 03/30/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Elevated cholesterol in type 2 diabetes mellitus (DM) can cause endothelial dysfunction. An effective clinical therapy to improve endothelial dysfunction remains to be established. Different cardiovascular actions between treatments for the inhibition of cholesterol absorption and the suppression of cholesterol synthesis for achieving improvement in endothelial function are unknown in DM. METHODS Stable patients with type 2 DM and mildly elevated low-density lipoprotein cholesterol were enrolled. We evaluated peripheral microvascular endothelial function using reactive hyperemia peripheral arterial tonometry (RH-PAT) examination and calculated a natural logarithmic transformed value for the RH-PAT index (LnRHI). We randomly assigned 33 patients to each monotherapy: cholesterol synthesis suppression using atorvastatin (5 mg/day, n=16) or cholesterol absorption inhibition using ezetimibe (10 mg/day, n=17). Patients were prospectively followed for 6 months. Serum lipids and LnRHI were repeatedly examined before and after each therapy. RESULTS LDL significantly decreased in both groups, but the percent changes of LDL showed a greater decrease in the atorvastatin group compared with the ezetimibe group (-34.5±7.8% vs. -21.9±9.6%, p<0.01). Serum levels of non-esterified free fatty acids (NEFA) significantly decreased in the ezetimibe group but not in the atorvastatin group (ezetimibe group: 561.1±236.8 to 429.7±195.9, p<0.01; atorvastatin group: 538.8±319.5 to 520.2±227.3, p=0.75). The percent decrease in NEFA was significantly greater in the ezetimibe group compared with the atorvastatin group (-19.9±27.4% vs. 11.3±44.1%, p<0.05). LnRHI showed a significant increase in the ezetimibe group but not in the atorvastatin group (ezetimibe group: 0.471±0.157 to 0.678±0.187, p<0.01; atorvastatin group: 0.552±0.084 to 0.558±0.202, p=0.64). The percent changes in LnRHI were significantly greater in the ezetimibe group compared with the atorvastatin group (63.3±89.2% vs. 7.4±41.2%, p<0.05). CONCLUSIONS In patients with type 2 DM, ezetimibe monotherapy significantly reduced LDL and NEFA, and improved peripheral microvascular endothelial dysfunction. Ezetimibe could potentially exhibit beneficial effects on lipid disorders and microvascular endothelial dysfunction in DM.
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Affiliation(s)
- Seigo Sugiyama
- Diabetes Care Center, Jinnouchi Hospital, 6-2-3 Kuhonji, Chuo-ku, Kumamoto, 862-0976, Japan. .,Diabetes Care Center, Cardiovascular Division, Jinnouchi Hospital, 6-2-3 Kuhonji, Chuo-ku, Kumamoto, 862-0976, Japan. .,Department of Cardiovascular Medicine, Faculty of Life Sciences, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 862-8556, Japan.
| | - Hideaki Jinnouchi
- Diabetes Care Center, Jinnouchi Hospital, 6-2-3 Kuhonji, Chuo-ku, Kumamoto, 862-0976, Japan. .,Diabetes Care Center, Cardiovascular Division, Jinnouchi Hospital, 6-2-3 Kuhonji, Chuo-ku, Kumamoto, 862-0976, Japan. .,Division of Preventive Cardiology, Department of Cardiovascular Medicine, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto, 862-8556, Japan.
| | - Kunio Hieshima
- Diabetes Care Center, Jinnouchi Hospital, 6-2-3 Kuhonji, Chuo-ku, Kumamoto, 862-0976, Japan.
| | - Noboru Kurinami
- Diabetes Care Center, Jinnouchi Hospital, 6-2-3 Kuhonji, Chuo-ku, Kumamoto, 862-0976, Japan.
| | - Tomoko Suzuki
- Diabetes Care Center, Jinnouchi Hospital, 6-2-3 Kuhonji, Chuo-ku, Kumamoto, 862-0976, Japan.
| | - Fumio Miyamoto
- Diabetes Care Center, Jinnouchi Hospital, 6-2-3 Kuhonji, Chuo-ku, Kumamoto, 862-0976, Japan.
| | - Keizo Kajiwara
- Diabetes Care Center, Jinnouchi Hospital, 6-2-3 Kuhonji, Chuo-ku, Kumamoto, 862-0976, Japan. .,Diabetes Care Center, Cardiovascular Division, Jinnouchi Hospital, 6-2-3 Kuhonji, Chuo-ku, Kumamoto, 862-0976, Japan.
| | - Kunihiko Matsui
- Department of Community Medicine, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto, 862-8556, Japan.
| | - Tomio Jinnouchi
- Diabetes Care Center, Jinnouchi Hospital, 6-2-3 Kuhonji, Chuo-ku, Kumamoto, 862-0976, Japan. .,Diabetes Care Center, Cardiovascular Division, Jinnouchi Hospital, 6-2-3 Kuhonji, Chuo-ku, Kumamoto, 862-0976, Japan.
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Ohbu-Murayama K, Adachi H, Hirai Y, Enomoto M, Fukami A, Obuchi A, Yoshimura A, Nakamura S, Nohara Y, Nakao E, Umeki Y, Fukumoto Y. Ezetimibe combined with standard diet and exercise therapy improves insulin resistance and atherosclerotic markers in patients with metabolic syndrome. J Diabetes Investig 2014; 6:325-33. [PMID: 25969718 PMCID: PMC4420565 DOI: 10.1111/jdi.12298] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 09/19/2014] [Accepted: 10/05/2014] [Indexed: 01/02/2023] Open
Abstract
Aims/Introduction Ezetimibe lowers serum lipid levels by inhibiting intestinal absorption of dietary and biliary cholesterol. However, the effect of ezetimibe on insulin resistance remains unclear. The aim of the present study was to examine this issue in patients with metabolic syndrome in local-dwelling Japanese, who were not being treated with lipid-lowering drugs. Materials and Methods In 2009, 1,943 participants received a health examination in the Tanushimaru Study, a Japanese cohort of the Seven Countries Study, of whom 490 participants had metabolic syndrome. Among them, 61 participants (41 men and 20 women) were examined in the present study. They were treated with 10 mg of ezetimibe once a day for 24 weeks, combined with standard diet and exercise therapy. Results Bodyweight (P < 0.001), body mass index (P < 0.001), systolic blood pressure (P = 0.003), diastolic blood pressure (P < 0.001), triglycerides (P = 0.002), non-high-density lipoprotein cholesterol (P = 0.001), low-density lipoprotein cholesterol (P < 0.001) and homeostasis model assessment of insulin resistance (P = 0.011) significantly decreased after the observational period. There were no statistically significant differences in the effects of ezetimibe between men and women. Univariate analysis showed that the reduction of homeostasis model assessment of insulin resistance was not associated with the improvement of other metabolic components. Conclusions Ezetimibe combined with standard diet and exercise therapy improves not only bodyweight and atherogenic lipid profiles, but also insulin resistance, blood pressure and anthropometric factors in metabolic syndrome in local-dwelling Japanese. Interestingly, the improvement of insulin resistance had no correlation with other metabolic components.
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Affiliation(s)
- Kyoko Ohbu-Murayama
- Department of Internal Medicine, Division of Cardio-Vascular Medicine Kurume, Japan
| | - Hisashi Adachi
- Department of Community Medicine, Kurume University School of Medicine Kurume, Japan
| | - Yuji Hirai
- Department of Internal Medicine, Division of Cardio-Vascular Medicine Kurume, Japan
| | - Mika Enomoto
- Department of Internal Medicine, Division of Cardio-Vascular Medicine Kurume, Japan
| | - Ako Fukami
- Department of Internal Medicine, Division of Cardio-Vascular Medicine Kurume, Japan
| | - Aya Obuchi
- Department of Internal Medicine, Division of Cardio-Vascular Medicine Kurume, Japan
| | - Ayako Yoshimura
- Department of Internal Medicine, Division of Cardio-Vascular Medicine Kurume, Japan
| | - Sachiko Nakamura
- Department of Internal Medicine, Division of Cardio-Vascular Medicine Kurume, Japan
| | - Yume Nohara
- Department of Internal Medicine, Division of Cardio-Vascular Medicine Kurume, Japan
| | - Erika Nakao
- Department of Internal Medicine, Division of Cardio-Vascular Medicine Kurume, Japan
| | - Yoko Umeki
- Department of Internal Medicine, Division of Cardio-Vascular Medicine Kurume, Japan
| | - Yoshihiro Fukumoto
- Department of Internal Medicine, Division of Cardio-Vascular Medicine Kurume, Japan
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Harbin M, Amadio A, Tejani A. Critical appraisal of the SHARP trial: the results may be dull. Clin Ther 2014; 36:2112-2117. [PMID: 25453731 DOI: 10.1016/j.clinthera.2014.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 07/14/2014] [Accepted: 10/07/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The goal of this commentary was to provide a critical analysis of the SHARP (Study of Heart and Renal Protection) trial. Published in 2011, this study has been used by clinicians to justify the prescribing of statins (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors) ±ezetimibe in patients with chronic kidney disease. METHODS We conducted a critical appraisal of the SHARP trial and associated documents (ie, US Food and Drug Administration review, SHARP protocol). We also examined background reviews and studies conducted before the SHARP trial to provide additional context and background. FINDINGS Our analysis provides clinicians with important criticisms of the SHARP trial, which suggest questionable clinical benefit to lipid-lowering therapy in patients with chronic kidney disease. IMPLICATIONS Our hope is that clinicians limit the broad prescription of statins (±ezetimibe) in all patients with chronic kidney disease (both dialysis and nondialysis) unless there is a valid reason for statin therapy (eg, existing cardiovascular disease).
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Affiliation(s)
- Megan Harbin
- Vancouver General Hospital, Vancouver, BC, Canada.
| | | | - Aaron Tejani
- Lower Mainland Pharmacy Services, Vancouver, BC, Canada
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9
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Williams LK, Padhukasahasram B, Ahmedani BK, Peterson EL, Wells KE, González Burchard E, Lanfear DE. Differing effects of metformin on glycemic control by race-ethnicity. J Clin Endocrinol Metab 2014; 99:3160-8. [PMID: 24921653 PMCID: PMC4154100 DOI: 10.1210/jc.2014-1539] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Metformin is considered first-line treatment for type 2 diabetes mellitus. However, little is known about its effects in African American individuals. OBJECTIVE The objective of the study was to assess whether metformin's effect on glycemic control differs by race-ethnicity Design: Electronic health records were used to identify adults who had a diagnosis of diabetes, two or more fills of metformin, and two or more glycated hemoglobin (HbA1c) measurements. Pharmacy claims were used to estimate metformin exposure based on fill frequency and dose dispensed. Regression analyses modeled the relationship between metformin exposure and HbA1c levels. Analyses were stratified by race-ethnicity and baseline HbA1c values. SETTING The study was conducted at a large health system in southeast Michigan. MAIN OUTCOME MEASURE Differences in HbA1c levels while on metformin were measured. RESULTS We identified 19 672 patients with diabetes taking metformin; 7429 were African American and 8783 were European American. Baseline HbA1c values in these two groups were 7.81% (61.8 mmol/mol) and 7.38% (57.1 mmol/mol), respectively. Compared with no use, metformin was associated with a 0.62% (6.8 mmol/mol) reduction in HbA1c; however, there was a significant difference by race-ethnicity (P < .001). Among African American individuals, metformin use was associated with a 0.90% (9.8 mmol/mol) reduction in HbA1c levels, whereas among European Americans, metformin was associated with a 0.42% (4.6 mmol/mol) reduction. Irrespective of baseline HbA1c, metformin use was associated with lower HbA1c levels in African American individuals. CONCLUSIONS African American individuals appear to have a better glycemic response to metformin when compared with European Americans. Further studies are needed to determine whether this translates to commensurate reductions in diabetes complications.
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Affiliation(s)
- L Keoki Williams
- Center for Health Policy and Health Services Research (L.K.W., B.P., B.K.A., D.E.L.), Department of Internal Medicine (L.K.W., D.E.L.), Department of Public Health Sciences (E.L.P., K.E.W.), Henry Ford Health System, Detroit, Michigan 48202; and Departments of Medicine (E.G.B.) and Bioengineering and Therapeutic Sciences (E.G.B.), University of California, San Francisco, San Francisco, California 94143
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Rosolová H, Dobiášová M, Soška V, Bláha V, Češka R, Nussbaumerová B, Pelikánová T, Souček M. Combined therapy of mixed dyslipidemia in patients with high cardiovascular risk and changes in the lipid target values and atherogenic index of plasma. COR ET VASA 2014. [DOI: 10.1016/j.crvasa.2014.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Szuszkiewicz-Garcia MM, Davidson JA. Cardiovascular disease in diabetes mellitus: risk factors and medical therapy. Endocrinol Metab Clin North Am 2014; 43:25-40. [PMID: 24582090 DOI: 10.1016/j.ecl.2013.09.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Cardiovascular disease is a serious complication of diabetes mellitus. In the last 2 decades, great strides have been made in reducing microvascular complications in patients with diabetes through improving glycemic control. Decreasing rates of cardiovascular events have proved to be more difficult than simply intensifying the management of hyperglycemia. A tremendous effort has been made to deepen understanding of cardiovascular disease in diabetes and to formulate the best treatment approach. This review summarizes the current state of knowledge and discusses areas of uncertainty in the care of patients with diabetes who are at risk for cardiovascular disease.
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Affiliation(s)
- Magdalene M Szuszkiewicz-Garcia
- Division of Endocrinology and Metabolism, Center for Human Nutrition, Department of Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8857, USA.
| | - Jaime A Davidson
- Division of Endocrinology, Diabetes and Metabolism, Touchstone Diabetes Center, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard K5.246, Dallas, TX 75390, USA
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12
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Pauriah M, Elder DHJ, Ogston S, Noman AYS, Majeed A, Wyatt JC, Choy AM, Macdonald TM, Struthers AD, Lang CC. High-potency statin and ezetimibe use and mortality in survivors of an acute myocardial infarction: a population-based study. Heart 2014; 100:867-72. [PMID: 24553389 DOI: 10.1136/heartjnl-2013-304678] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine all-cause mortality in patients with a first myocardial infarct who were treated with simvastatin compared with high-potency statin and simvastatin/ezetimibe combination. BACKGROUND Despite statin use, residual cardiovascular risk remains. Therapeutic options include more potent statins or addition of ezetimibe. There is no clinical outcome data on the use of ezetimibe in such patients. METHODS Retrospective longitudinal study using the United Kingdom General Practice Research Database. Patients who had survived 30 days after their first acute myocardial infarct (AMI), had not received prior statin or ezetimibe therapy and were started on a statin within 30 days of AMI were included. Three groups were identified according to their follow-up: (i) simvastatin monotherapy; (ii) high-potency statin group (patients who started on simvastatin and switched to atorvastatin or rosuvastatin); and (iii) ezetimibe/statin combination group (patients who received ezetimibe in addition to statin). RESULTS 9597 patients (57% male, mean age of 65 ± 13 years) matched study criteria: simvastatin (n=6990 (72.8%)); high-potency statin (n=1883, (19.6%)); and ezetimibe/statin combination (n=724 (7.5%)). During a mean follow-up of 3.2 years, there were 1134 (12%) deaths. In the multivariate proportional hazards model, the adjusted HR for high-potency statin and ezetimibe group were 0.72 (95% CI 0.59 to 0.88, p<0.001) and 0.96 (95% CI 0.64 to 1.43, p=0.85), respectively. A similar result was also obtained in the propensity score analysis that took into account covariates that predicted drug treatment groups. CONCLUSIONS Patients switched to a high-potency statin had a significantly reduced mortality compared with simvastatin monotherapy. There was no observed mortality benefit in the ezetimibe group.
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Affiliation(s)
- Maheshwar Pauriah
- Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital and Medical School, University of Dundee, , Dundee, UK
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Sumarokov AB, Kukharchuk VV. [Hypolipidemic and pleiotropic effects of a combination of simvastatin and ezetimibe in patients with different types of hyperlipidemia]. TERAPEVT ARKH 2014; 86:107-15. [PMID: 25804051 DOI: 10.17116/terarkh20148612107-115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The review considers trials dealing with the efficiency of combination hypolipidemic therapy with simvastatin and ezetimibe. Its synergistic potentiating effect can cause a considerable decrease in the level of total cholesterol, low-density lipoproteins, triglycerides, and C-reactive protein, which are important participants in the atherogenic process. This effect promotes the achievement of hypolipidemic therapeutic goals in many cases when this cannot be attained by high-dose statin monotherapy. The authors consider the results of trials of combination hypolipidemic therapy with simvastatin and ezetimibe performed as basic ones done in both previous and recent years.
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Doggrell SA. Comment on: Clinical benefits of ezetimibe: absence of proof is just that. Expert Opin Pharmacother 2013; 14:2611-2. [DOI: 10.1517/14656566.2013.849063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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