Taking aim at HDL-C

Fulvestrant: pharmacologic profile versus existing endocrine agents for the treatment of breast cancer

OBJECTIVE

To compare the pharmacologic profile of fulvestrant with that of tamoxifen and the aromatase inhibitors with respect to the choice of treatment for advanced breast cancer (ABC).

DATA SOURCES

Principal literature and review articles were obtained from MEDLINE (1991-March 2006). Key search terms included fulvestrant, tamoxifen, aromatase inhibitors, pharmacology, and breast cancer. Further data sources were identified from the bibliographies of selected articles.

STUDY SELECTION AND DATA EXTRACTION

English-language preclinical and clinical research and review articles reporting pharmacologic and safety data for fulvestrant, tamoxifen, and the aromatase inhibitors were evaluated to identify relevant information. Randomized clinical trial data were preferred over preclinical or Phase I and II trial data.

DATA SYNTHESIS

A total of 52 clinical papers (including 10 reviews) and 17 clinical abstracts were evaluated reporting results from controlled Phase I-III studies and pilot studies. Eleven preclinical papers (including 2 reviews) and 6 preclinical abstracts were also included. Fulvestrant has little effect on sex hormone endocrinology, bone metabolism, and lipid biochemistry and appears unlikely to be the subject or cause of CYP3A4-mediated drug interactions. Tamoxifen has a protective effect on bone (due to its partial estrogen agonist activity) and reduces plasma low-density lipoprotein cholesterol but increases triglyceride levels. The aromatase inhibitors have variable effects on lipid profiles and sex hormone endocrinology but have detrimental effects on bone due to inhibition of estrogen synthesis. Drug interactions have been noted between tamoxifen and anticoagulants and tamoxifen and aromatase inhibitors, which may be due to CYP-mediated mechanisms.

CONCLUSIONS

Fulvestrant appears to have little effect on sex hormone endocrinology, bone metabolism, and lipid biochemistry and is unlikely to be subject to or the cause of CYP3A4-mediated drug-drug interactions. As such, fulvestrant represents a valuable new endocrine therapy for the treatment of ABC and broadens the options available to clinicians in the treatment of this disease.

Gender difference in the level of high-density lipoprotein cholesterol in elderly Japanese patients with coronary artery disease

OBJECTIVE

High-density lipoprotein cholesterol (HDLC) levels are known to be reduced in the metabolic syndrome, but the HDLC profile of elderly patients with coronary artery disease (CAD) has not been well characterized. This study investigated the gender difference of HDLC levels in elderly Japanese patients with CAD.

METHODS

Serum lipid data were analyzed retrospectively to assess sex-related differences of the lipid profile, and to evaluate the effects of pharmacotherapy or physical exercise on hyperlipidemia.

PATIENTS

A total of 163 elderly (> or = 65 years) outpatients with CAD (128 men aged 70.6+/-5.2 years and 35 women aged 74.1+/-6.0 years [mean+/-SD]) were investigated.

RESULTS

The mean total cholesterol (TC), low-density lipoprotein cholesterol (LDLC), and triglyceride (TG) levels were similar in men and women, while the mean HDLC level was significantly higher in women than men (58.3+/-18.1 vs. 50.3+/-13.5 mg/dL; p=0.0064). The HDLC level was not significantly influenced by oral lipid-lowering therapy or regular exercise in either sex. However, women without lipid-lowering therapy had significantly higher HDLC levels than men with (p=0.0312) or without (p=0.0338) lipid-lowering therapy, while women performing regular exercise had significantly higher HDLC levels than men with (p=0.0047) or without (p<0.001) regular exercise.

CONCLUSION

Elderly women with CAD have higher HDLC levels relative to their postmenopausal state than those of men with CAD. Low HDLC levels, unlike in men, may not be a major risk factor for CAD in elderly women.

Cost-effectiveness of HMG-CoA reductase inhibitors in the treatment of dyslipidemia and prevention of CHD

The recent completion of several clinical trials of lipid-lowering therapy with 3-hydroxy-3-methylglutaryl coenzyme A inhibitors, or statins, was followed by an update in 2004 concerning the Adult Treatment Panel III guidelines issued by the National Cholesterol Education Program. Within this update, individuals considered at very high risk for coronary heart disease-related events were addressed, wherein the role of an aggressive, intensive lowering of lipid levels to new goals was presented. In achieving target cholesterol levels, the statins collectively represent first-line pharmacotherapeutic strategies, although each of the currently marketed agents differ in relative potency, dose, side effects and cost. As such, research concerning the pharmacoeconomics of lipid-lowering therapy may serve to augment clinical, evidence-based approaches to care. Furthermore, identifying and rectifying suboptimal care within healthcare systems may afford optimal outcomes amongst patients for resources consumed.