Home' Australian Pharmacist : August 2011 Contents Vol. 30 -- August #08
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significant reduction in mortality with
intensive statin therapy, compared with
moderate or low dose statin therapy.
Neither did it find a linear relationship
between LDL cholesterol lowering and
cardiovascular risk reduction.29
1. Due to the lack of evidence to
support an LDL cholesterol level of
less than 1.8/1.9 mmol/L, it appears
unnecessary for Mr GS to continue
the ezetimibe. It was suggested
to his GP to consider stopping
ezetimibe and he was notified that
this would probably cause a rebound
increase in LDL of about 20% (as
this is the likely reduction in LDL
that the agent originally caused).
The GP agreed and ceased the
ezetimibe. Lipids were re-tested
4 weeks later and his LDL was
2. Mr GS was informed that 2 g
of fish oils per day may not be
sufficient due to his history of
heart disease. He rarely eats
fish and so was encouraged to
increase fish oils to 4 g per day.
1. Writing Group for Therapeutic Guidelines.
Cardiovascular Monograph [CD-ROM]. North
Melbourne: Therapeutic Guidelines; Mar 2011.
2. National Prescribing Service. CVD Risk: Guiding lipid
management. Educational Visiting Card. Mar 2011.
3. National Prescribing Service. Managing Lipids. NPS
News 71 [online]. 2011 [accessed 28 May 2011].
At: www.nps.org.au/healthpro [Go to Quick Links,
Newsletter Index, NPS News 71].
4. O'Keefe JH, Carter MD, Lavie CJ. Primary and
secondary prevention of cardiovascular diseases: A
practical evidence-based approach. Mayo Clin Proc.
5. National Heart Foundation of Australia. Position
statement. Fish, fish oils, n-3 polyunsaturated fatty
acids and cardiovascular health. Updated 2008.
6. National Prescribing Service. CVD risk: Guiding lipid
management. Background Materials. Nov 2010.
7. Braun L, Cohen M. Herbs & Natural Supplements: An
evidence-based guide. 3rd edn. Elsevier Australia;
8. Colquhoun D. Explaining Omacor. Aust Pharmacist.
9. Australia Prescriber. An independent review: New
Drugs. Omega-3-acid ethyl esters. Aust Prescr. 2010;
10. National Heart Foundation. Omega-3 levels
in Fish and Seafood [online]. 2008 [accessed
on 29 May 2011] At: www.heartfoundation.
11. Neal MJ. Medical pharmacology at a glance. 5th edn.
Cornwall: Blackwell Publishing; 2005. pp 64--5.
12. McKenney JM. Dyslipidemias, atherosclerosis and
coronary heart disease. In: Koda-Kimble MA, Young
LY, Kradjan WA, et al, eds. Applied therapeutics: The
clinical use of drugs. 8th edn. Lippincott Williams &
Wilkins; 2005. p 13.
13. MRC/BHF Heart Protection Study of cholesterol
lowering with simvastatin in 20,536 high-risk
individuals: a randomised placebo-controlled trial.
Lancet. 2002; 360:7--22.
14. Rossi S, ed. Australian Medicines Handbook. Adelaide:
15. Venero CV, Thopson PD. Managing statin myopathy.
Endocrinol Metab Clin North Am. 2009; 38(1):121--36.
16. Eadie MJ. e-MIMS [CD-ROM], St Leonards:
MediMedia Australia; Mar 2011.
17. Joy TR, Hegele RA. Narrative Review: Statin-related
myopathy. Ann Intern Med. 2009; 150:858--68.
18. Mills EJ, Wu P, Chong G, et al. Efficacy and safety of
statin treatment for cardiovascular disease: a network
meta-analysis of 170,255 patients from 76 randomized
trials [online]. 2011 [accessed 25 May 2011]. At:
19. Ridker PM, Danielson E, Fonseca FA, et al.
Rosuvastatin to prevent vascular events in men and
women with elevated C-reactive protein. NEJM.
2008 Nov 20; 359(21):2195--207.
20. Marcoff L, Thompson PD. The role of coenzyme Q10
in statin-associated myopathy: a systematic review.
J Am Coll Cardiol. 2007: 49:2231--7.
21. Davignon J, Leiter LA. Ongoing clinical trials of
the pleiotropic effects of statins. Vasc Health Risk
Manag. 2005 Mar; 1(1): 29--40.
22. Makris GC, Lavida A, Nicolaides AN, et al. The effect
of statins on carotid plaque morphology: a LDL-
associated action or one more pleiotropic effect of
statins? Atherosclerosis. 213: 8--20.
23. Pasterkamp G, van Lammeren GW. Pleiotropic
effects of statins in atherosclerotic disease. Expert
Rev Cardiovasc Ther. 2010; 8:1235--7.
24. Thompson, PD, Buchner D, Piña IL, et al. Exercise and
physical activity in the prevention and treatment of
atherosclerotic cardiovascular disease. Circ. 2003;
25. Henyan NN, et al. Impact of statins on risk of
stroke: A meta-analysis: Discussion. Annals of
Pharmacotherapy. 2007; 41(12):1937--45.
26. Beom JK, et al. Low level of low-density lipoprotein
cholesterol increases hemorrhagic transformation
in large artery atherothrombosis but not in
cardioembolism. Stroke. 2009; 40:1627.
27. Yang X, et al. Independent associations between
low-density lipoprotein cholesterol and cancer
among patients with type 2 diabetes mellitus.
CMAJ. 179(5): 427--37.
28. Goldstein MR, Mascitelli L. Statin-induced diabetes:
perhaps, it's the tip of the iceberg. QJM Advance
Access. 30 Nov 2010.
29. NPC Rapid Review. New meta-analysis on intensive
statin therapy supports NICE guidance [online].
2011 [accessed 26 May 2011]. At: www.npc.nhs.uk/
30. National Heart Foundation of Australia. National
Vascular Disease Prevention Alliance Guidelines for
the assessment of absolute cardiovascular disease
1. A statin dose that lowers LDL
cholesterol by 30--40% will
result in what percentage
reduction in cardiovascular
2. Which of the following are
common adverse effects of
a) Headache, dizziness.
d) All of the above.
3. A 58-year-old gentleman enters
the pharmacy complaining of
non-specific muscle aches and
weakness. He commenced 20
mg atorvastatin several weeks
ago. What should be the FIRST
thing you do?
a) Sell him a Coenzyme Q10
supplement to counter the muscle
b) Ask about compliance with his
c) Ask if he has recently increased
his activity levels.
d) Tell him to cease atorvastatin
immediately and see his doctor.
4. Which of the following
statements regarding LDL
cholesterol levels in secondary
prevention of cardiovascular
disease is CORRECT?
a) LDL cholesterol levels should be
reduced to the lowest attainable
level using multiple medications.
b) Lowering LDL cholesterol levels
aggressively to significantly less
than 2.0 mmol/L does not have
a strong evidence base and may
increase the risk of adverse
A score of 4 out of 5 attracts 1 CPD credit.
c) The recommended LDL cholesterol
level for this patient group is 1.7
5. For those with a documented
history of coronary heart
disease, the recommended
dose of fish oils per day is:
a) 1.5 g.
c) 3--4 g.
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