A multi-centre, randomised, double-blind 14-week extension study examining the long-term safety and efficacy profile of the ezetimibe/simvastatin combination tablet

Comparing remnant lipoprotein cholesterol measurement methods to evaluate efficacy of ezetimibe/statin vs statin therapy

BACKGROUND

Elevated remnant lipoprotein cholesterol (RLP-C) levels increase cardiovascular disease risk. However, RLP-C measurement methods are not standardized, leading to variations across studies.

OBJECTIVE

To evaluate the effect of ezetimibe (Eze) + statins vs statin monotherapy on RLP-C using immunoseparation (IM), vertical auto profile (VAP) ultracentrifugation, and calculated RLP-C measurement methods.

METHODS

This post hoc analysis evaluated data pooled from 3 first-line (all-statin [simvastatin 10/20/40/80 mg] vs Eze + statin [Eze 10 mg + simvastatin]) and 2 second-line (statin [atorvastatin uptitrated to 40/80 mg] vs statin + Eze [atorvastatin 20/40 mg + Eze 10 mg]) studies. Similarity of RLP-C methods was evaluated using Pearson correlation coefficients and Bland-Altman plots. RLP-C changes and percent changes from baseline were measured by all 3 methods in first-line and VAP and calculated methods in second-line studies.

RESULTS

Correlations between methods were generally moderate to strong for RLP-C levels, changes, and percent changes across treatment groups (r = 0.29-0.79) but with little evidence of agreement by Bland-Altman plots. Baseline RLP-C levels for Eze + statin vs all-statin groups were lower by IM (14.0 vs 14.0) compared with VAP (36.9 vs 35.9) and calculated (32.8 vs 33.3) methods. RLP-C changes (mg/dL) and percent changes from baseline were significantly greater (P < .01) with Eze + statins vs statins by VAP, calculated, and IM methods (between-treatment differences: -5.0 and -12.0, -2.0 and -5.4, and -1.5 and -12.1, respectively) in first-line, and VAP and calculated methods (between-treatment differences: -5.0 and -19.9 and -2.0 and -7.3) in second-line studies.

CONCLUSION

Although the 3 methods showed little agreement, each supported Eze + statins for achieving greater RLP-C reductions vs statin monotherapy; variability of results reinforces urgent need to standardize RLP-C measurements.

The efficacy and safety of ezetimibe and low-dose simvastatin as a primary treatment for dyslipidemia in renal transplant recipients

BACKGROUND/AIMS

The efficacy and safety of a combination of ezetimibe and low-dose statin as primary treatment for dyslipidemia in renal transplant patients were evaluated prospectively.

METHODS

The study enrolled 77 renal transplant recipients with dyslipidemia. They were given ezetimibe (10 mg) and simvastatin (10 mg) for 6 months as the initial treatment for dyslipidemia. Efficacy and safety were evaluated using lipid profiles, trough calcineurin inhibitor levels, allograft function, and adverse effects. The effects on proteinuria and high sensitivity C-reactive protein (hsCRP) levels were also evaluated.

RESULTS

Ezetimibe and low-dose simvastatin significantly decreased the levels of total cholesterol (34.6%), triglyceride (16.0%), and low-density lipoprotein cholesterol (LDL-C) (47.6%), and 82.5% of the patients reached the target LDL-C level of <100 mg/dL. No significant change in the trough calcineurin inhibitor levels or allograft function occurred, and no serious adverse effects were observed. Fourteen patients (18.2%) discontinued treatment; eight patients (11.7%) developed muscle pain or weakness without an increase in creatinine kinase levels, and two patients (2.6%) developed elevated liver transaminase levels. The proteinuria and hsCRP levels did not change significantly.

CONCLUSIONS

Ezetimibe and low-dose statin treatment is safe and effective as a primary treatment for dyslipidemia in renal transplant patients.

Tolerability and effects on lipids of ezetimibe coadministered with pravastatin or simvastatin for twelve months: results from two open-label extension studies in hypercholesterolemic patients

OBJECTIVE

The aim of these studies was to assess the long-term tolerability and effects on lipids of ezetimibe coadministered with pravastatin or simvastatin during treatment of hypercholesterolemic patients.

METHODS

Two separate 12-month, open-label extension studies enrolled patients who had successfully completed one of three 12-week, double-blind, placebo-controlled trials of ezetimibe coadministered with pravastatin, lovastatin, or simvastatin. In the extensions, the initial dose of each drug administered was 10 mg/d, with the option to up-titrate the statins if low-density lipoprotein cholesterol (LDL-C) goals were not met. Tolerability was assessed using monitoring of clinical and laboratory adverse events (AEs). Changes from baseline in LDL-C, total cholesterol, high-density lipoprotein cholesterol, and triglyceride levels were calculated.

RESULTS

Overall, 436 patients received ezetimibe + pravastatin 10 to 40 mg/d, including patients from the parent studies who received coadministration treatment but did not continue in the extension studies; 359 patients received ezetimibe + simvastatin 10 to 80 mg/d in the extension study. The majority of patients in both studies were white (ezetimibe + pravastatin, 374 [86%]; ezetimibe + simvastatin, 314 [87%]) and female (ezetimibe + pravastatin, 246 [56%]; ezetimibe + simvastatin, 210 [58%]). The mean ages were 55.7 and 57.7 years and the mean body mass indexes were 29.4 and 28.8 kg/m2 in the ezetimibe + pravastatin and ezetimibe + simvastatin studies, respectively. The most commonly reported AEs with ezetimibe + pravastatin were upper respiratory tract infection (78 [18%]), headache (47 [11%]), musculoskeletal pain (45 [10%]), arthralgia (43 [10%]), and sinusitis (42 [10%]); with ezetimibe + simvastatin, they were upper respiratory tract infection (67 [19%]), arthralgia (39 [11%]), and musculoskeletal pain (37 [10%]). AEs considered treatment related were reported in 98 (22%) and 80 (22%) patients in the ezetimibe + pravastatin and ezetimibe + simvastatin studies, respectively. Serious AEs were reported in 29 patients (7%) who received ezetimibe + pravastatin and 36 patients (10%) who received ezetimibe + simvastatin; <1% were considered treatment related in either study. Forty-one (9%) and 29 patients (8%), respectively, were withdrawn due to AEs. One death occurred due to cardiopulmonary arrest in the ezetimibe + simvastatin study and was not considered treatment related. Percentage changes from baseline in LDL-C were -36.5% and -40.4% in patients who received ezetimibe + pravastatin and ezetimibe + simvastatin.

CONCLUSION

In these 12-month, open-label extension studies in these patients with hypercholesterolemia, ezetimibe + pravastatin or simvastatin was generally well tolerated. Both treatments were associated with maintaining improvements in lipid parameters throughout the studies in these patients.

Long-term safety and tolerability of ezetimibe coadministered with simvastatin in hypercholesterolemic patients: a randomized, 12-month double-blind extension study

OBJECTIVES

To assess the long-term safety and tolerability and to further evaluate the effect of ezetimibe plus simvastatin on LDL-C, HDL-C, and triglyceride levels in subjects with primary hypercholesterolemia.

METHODS

This was a 12-month, double-blind, placebo-controlled extension study that enrolled patients with primary hypercholesterolemia who had successfully completed the 12-week, double-blind, placebo-controlled trial of ezetimibe coadministered with simvastatin. The initial dose administered to patients in the extension was ezetimibe 10 mg coadministered with simvastatin 10 mg with the option to up-titrate statin dosage if LDL-C goals were not met. Safety and tolerability were assessed through clinical and laboratory adverse experiences (AEs). Changes from baseline in low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and triglyceride levels were measured.

RESULTS

Overall, 87 patients were randomized to receive ezetimibe + simvastatin and 22 were randomized to receive simvastatin and placebo. Treatment-emergent AEs were reported for 72/87 (83%) ezetimibe + simvastatin-treated patients and for 17/22 (77%) simvastatin-treated patients. The most commonly reported AEs in the simvastatin treatment group were hypertension, gastro-esophageal reflux, and musculoskeletal pain (each reported by 3/22 [14%] patients); and in the ezetimibe + simvastatin group were upper respiratory tract infection (16/87 [18%]), arthralgia and musculoskeletal pain (both reported by 10/87 [11%] patients). Drug-related AEs were reported for 3/22 (14%) simvastatin-treated patients and 21/87 (24%) patients in the coadministration group. AEs considered serious by the investigator were reported by 2/22 (9%) patients taking simvastatin monotherapy and by 20/87 (23%) patients taking ezetimibe + simvastatin. Discontinuations due to AEs occurred in no patients taking simvastatin monotherapy and in 7/87 (8%) patients taking ezetimibe + simvastatin. Percent change ± standard deviation from baseline in LDL-C was -29% ± 15.4 and -44% ± 14.2 in subjects taking simvastatin monotherapy and ezetimibe + simvastatin, respectively.

CONCLUSIONS

Ezetimibe coadministered with simvastatin was generally well-tolerated and no new safety concerns were raised. Both treatments effectively maintained improvements in lipid parameters throughout the course of the studies. Interpretation of these results was limited by the small convenience sample included in the trial.

Long-term (48-week) safety of ezetimibe 10 mg/day coadministered with simvastatin compared to simvastatin alone in patients with primary hypercholesterolemia

OBJECTIVE

This study evaluated the long-term safety and tolerability of ezetimibe/simvastatin coadministration therapy compared to simvastatin monotherapy in patients with primary hypercholesterolemia.

RESEARCH DESIGN AND METHODS

After completing a 12-week randomized, double-blind, placebo-controlled, factorial, 10-armed study comparing ezetimibe 10 mg/simvastatin 10, 20, 40, or 80 mg; simvastatin 10, 20, 40, or 80 mg; ezetimibe 10 mg; or placebo, 768 patients entered a 48-week extension, with randomized, blinded, reassignment of the simvastatin 10 mg, ezetimibe, and placebo groups to one of the ezetimibe/simvastatin groups. Patients previously receiving ezetimibe/simvastatin combination therapy, or simvastatin 20, 40, and 80 mg monotherapy continued the same therapies in this 7-arm extension study. During the extension study, investigators assessed adverse events (AEs).

MAIN OUTCOME MEASURES AND RESULTS

Ezetimibe/simvastatin (n = 539) and simvastatin monotherapy (n = 229) groups generally had a similar incidence of all clinical AEs (73 vs. 69%), treatment-related AEs (14 vs. 11%), clinical serious AEs (SAE) (5.2 vs. 2.6%), treatment-related SAEs (0.2 vs. 0%), discontinuations due to all clinical AEs (4.5 vs. 2.6%) and discontinuations due to treatment-related AEs (2.8 vs. 2.2%), respectively. The incidence of total laboratory-related AEs for the ezetimibe/simvastatin and simvastatin monotherapy groups was also similar (12.2 vs. 11.9%), as was treatment-related laboratory AEs (6.2 vs. 5.3%), laboratory SAEs (0 vs. 0%), treatment-related laboratory SAEs (0 vs. 0%), discontinuations due to laboratory AEs (3.0 vs. 0.9%) and discontinuations due to treatment-related laboratory AEs (3.0 vs. 0.4%), respectively. There were no cases of myopathy, rhabdomyolysis, or serious hepatotoxicity observed in any group during this extension study.

CONCLUSIONS

During this 48-week extension study, the coadministration of ezetimibe/simvastatin was generally as well tolerated as simvastatin monotherapy. The direct application of study observations to clinical practice is limited by patient selection criteria and dosage regime, which randomly applied relatively high doses rather than titration which often occurs in clinical practice.

Efficacy and safety of ezetimibe and ezetimibe plus statin therapy in patients aged under 65, 65–74 and 75 years and older

Although the greatest burden of cardiovascular disease occurs after age 65 years, limited efficacy and safety data are available for cholesterol-lowering drugs in elderly patients. We undertook a pooled analysis of individual data from 13,282 patients aged 18–93 years in 16 published trials of ezetimibe and ezetimibe added on to or coadministered with a statin (ezetimibe/statin). Overall, ezetimibe reduced low-density lipoprotein cholesterol by 20% compared with placebo and ezetimibe/statin reduced low-density lipoprotein cholesterol by 17% compared with a statin alone, with consistent treatment effects across age groups (<65, 65–74 and ≥75 years). Rates of any adverse or drug-related adverse events were also similar across age groups. We conclude that the lipid efficacy and safety of ezetimibe and ezetimibe/statin in those aged 65–74 and 75 years and older are similar to those observed in patients aged under 65 years.