The National Cholesterol Education Program (NCEP) has recently issued new guidelines for cholesterol management. The new guidelines are known as Adult Treatment Panel III (ATP III), to distinguish them from earlier recommendations. The new guidelines continue to emphasize LDL cholesterol as the primary focus of lipid management, but consider other variables to assess risk of a cardiac event.

Here's a brief description of the new recommendations:

1. All adults aged 20 years or older undergo a fasting lipid profile (total cholesterol, LDL-C, HDL-C and triglycerides) once every five years. The results of this test should be considered along with other major risk factors, including:

• Cigarette smoking
• Hypertension
• Low high-density lipoprotein (HDL) cholesterol (less than 40 mg/dL)
• A family history of premature coronary heart disease
• Age of 45 years or older for men and 55 or older for women
  

2. LDL levels of less than 100 mg/dL are now defined as optimal for the entire population

The new guidelines make their most important contributions in refining risk prediction for people without coronary disease - and recommending that the highest-risk individuals be treated as if they already had this diagnosis because their risk is equivalent to that of patients with CAD.

3. High Risk (Coronary Heart Disease Equivalents)

• Greater than 20% ten year risk of coronary event by Framingham global risk score
• Atherosclerosis (includes peripheral arterial disease, AAAs, those with TIAs and strokes)
• Diabetes

4.Importance of identification and management of patients with the Metabolic Syndrome-obesity, lipid abnormalities, elevated serum glucose, hypertension

Previous studies have suggested that only about 1/3 of patients treated actually reach the old goals of 130mg/dL-160mg/dL in primary prevention and 100mg/dl in secondary prevention.¹ The new guidelines increase the number of people needing to significantly lower their LDL serum levels. This is likely to further reduce the percentage of patients actually attaining the desired goal. Part of the problem undoubtedly relates to a problem with compliance.² Problems with compliance and persistence are likely to be multifactorial. Price may be an important factor, especially for elderly patients, who pay out-of-pocket for prescription drugs.

Please Note: Baycol was voluntarily removed from the U.S. market on August 8, 2001. For further information please see the August Newsletter.

And, speaking about price…

The new NCEP guidelines will further increase drug costs while presumably reducing healthcare costs overall. Efficient prescribing will be required for this equation to balance. But, how are we prescribing the statins? IMS Health and other data warehouses compile prescription drug statistics for all of the major classes of drugs. The pharmaceutical industry uses these data to enhance the market share of their products. Here is what the statin market looked like in terms of numbers of prescriptions dispensed in 2000 on a national level:

Some observations are worth mentioning:

• Assuming a pretreatment LDL level of 130mg/dL, the most commonly prescribed doses of Pravachol and Mevacor are barely adequate to reach a defined goal of 100mg/dL.
  
  
• Assuming a pretreatment LDL level of 160mg/dL, only the most commonly prescribed doses of Baycol (Withdrawn 8/8/2001), Lipitor and Zocor will allow most patients to reach a defined goal of 100mg/dL
  
  
• Here's what it will cost to get the patient to goal using the most commonly prescribed doses of Baycol, Lipitor and Zocor:

References:

1. Pearson TA, Laurora I, Chu H, Kafonek S. The lipid treatment assessment project (L-TAP). Arch Intern Med 2000; 160:459-467.
2. Avorn J, Monette J, Lacour A, et al. Persistence of use of lipid-lowering medications. JAMA 1998; 279(18):1458-1462.