How to control blood lipids?
1.Effective drug effective dose
According to the latest guidelines for the prevention and treatment of adult dyslipidemia in China, the total LDL-C compliance rate is 50%; according to the ATP III standard, the total LDL-C compliance rate is 34%, among which the compliance rate for those taking statins is 36%. Despite the high proportion of patients taking statins, the actual attainment rate is still low.
In China, the doses of statins used by physicians are small, and the concerns of physicians and patients about the safety of statins hinder the full use of statins, which is more prominent in primary care units such as secondary care hospitals, where the standard dose of statins is often not achieved or the dose is reduced after the standard is achieved. There is a need to clarify incorrect perceptions about the safety of statins. Not only should effective drugs be used in clinical practice, but also the need to apply effective doses must be emphasized, following the principle of double effectiveness, and double effectiveness is true effectiveness.
2.Long-term attainment
Cardiovascular disease is a chronic disease, the prevention and treatment of cardiovascular disease requires long-term intervention, or even lifelong treatment. Secondary prevention drugs for coronary heart disease, including statins, need long-term use, long-term medication and long-term benefits. The Second Multicenter Collaborative Study on the Status of Clinical Lipid Control in China enrolled patients who had been taking lipid-lowering medications for at least 2 months, and did not provide the average duration of taking medications, which, according to some data, is generally several months and is not representative of patients’ long-term compliance. Therefore, the attainment rates provided by the study are short-term attainment rates. For patients with stable coronary artery disease, it generally takes about 2 years for statins to have a significant reduction in cardiovascular events and for patients to have a significant improvement in prognosis. Therefore, the long-term medication attainment rate of our patients is more meaningful, however, it is not optimistic.
3. Intensive lipid lowering for high-risk groups
Along with the continuous expansion of evidence-based research and the continuous updating of clinical guidelines, the concept of lipid-lowering treatment has been developing and the understanding of statin has been deepening. Lipid-lowering guidelines based on evidence (European guidelines, U.S. guidelines and our adult dyslipidemia prevention and treatment guidelines) continue to lower the target value of LDL-C reduction in high-risk groups: “Lower LDL-C is better.”
Increasing the statin dose not only increases the financial burden on patients, but also raises concerns about the safety of high-dose statins. As a result, the ATP III revision states that lowering LDL-C levels to 70 mg/dl in very high-risk patients is not possible when baseline LDL-C is >150 mg/dl. It is also difficult to meet the target for the national population with rising cholesterol levels. This requires the development of new lipid-lowering drugs and the opening up of new lipid-lowering pathways.
Combination lipid-lowering – an intensive path to lower lipids
Statins have become the first choice for lipid-lowering treatment with their potent lipid-lowering efficacy, significant prognosis improvement and good safety, and are indispensable treatment methods for atherosclerosis disease intervention. It has set off a statin revolution in lipid-lowering therapy worldwide. However, relying solely on increasing the dose of statin not only provides limited lipid-lowering efficacy, but also increases the proportion of adverse effects. This undoubtedly increases the difficulty of treatment.
Therefore, due to the need for intensive clinical lipid lowering and the limitation of lipid-lowering efficacy and side effects of drugs, in addition to the development of new and more potent lipid-lowering drugs, the combination of lipid-lowering drugs is also a development direction of lipid-lowering therapy.
The objectives of combination lipid-lowering are to.
(1) to improve the attainment rate, which cannot be achieved in a significant proportion of patients using a single lipid-lowering drug.
(2) To give full play to the complementary synergistic effects of drugs and facilitate comprehensive lipid regulating therapy.
(3) To reduce dose-related adverse effects.
(4) Reducing the number of test follow-ups, facilitating patients and improving treatment adherence.
Theoretically, the combination of drugs with different mechanisms of action can be used. In patients with severe hypercholesterolemia, statins + bile acid chelators, statins + cholesterol absorption inhibitors, or statins + bile acid chelators/cholesterol absorption inhibitors + niacin can be used if single agents are ineffective; statins + betablockers/niacin or statins + resins/niacin can be used in the presence of mixed dyslipidemia. Statin-based combinations have become the preferred regimen for cholesterol-lowering therapy.
In terms of cholesterol lowering, the combination of statin + cholesterol absorption inhibitor is by far the best choice. The dual blockage of cholesterol synthesis and absorption by both drugs not only significantly enhances lipid lowering, but also avoids the increased feedback gastrointestinal cholesterol absorption caused by statin alone. The LDL-C reduction is only 6% when the statin dose is doubled, while the addition of cholesterol absorption inhibitors can reduce LDL-C by an additional 18%-25%, which is equivalent to the efficacy of the statin dose after 3 times doubling.
In addition, cholesterol uptake inhibitors are not metabolized by the hepatic cytochrome P450 system, and no clinically significant drug-drug pharmacokinetic interactions have been observed with the combination. Treatment with cholesterol absorption inhibitors alone does not require monitoring of safety indicators. If combined with a statin, safety indicators such as liver enzymes and creatine kinase need to be monitored.