Pharmacy Pearl 12 January 2000

A medical intern wants to order a non-contracted statin (HMG CoA reductase inhibitor) for his patient because he had an elevated LDL CHOL (>200 mg/dL) and an elevated TRIG level (>400 mg/dL). The patient had no other medical problems. His labs, other than his lipids, were within normal limits. His rationale was that the DoD contracted statins (cerivastatin, simvastatin) did not have the degree of TRIG lowering that the non-contract statin did.

Do you agree with the intern? Do you approve the non-formulary drug request?

SELECT here for discussion

There's has been a lot of discussion about the TRIG-lowering effects of various statin drugs. There's also significant disagreement whether TRIGs are a risk factor in coronary heart disease (CHD). IF you decide to treat a patient with hypertriglyceridemia to prevent either pancreatitis or CAD, here's some things to consider:

1) Elevated triglycerides (TRIG) are NOT an independent risk factor for the development of coronary heart disease (CHD), as defined by the National Cholesterol Education Program (NCEP). Hypertriglyceridemia (> 500 or 1000) is a risk factor for the development of pancreatitis. Hypertriglyceridemia in select populations (ex. patients with diabetes, nephrotic syndrome, chronic renal disease) may serve as a surrogate marker for CHD.

2) Providers should focus their efforts on other CHD risk factors that will pay greater benefits like weight loss, smoking cessation, LDL lowering, hypertension control, diabetes control, and HDL elevation.

3) When given in equipotent doses, there is no significant difference in the TRIG lowering properties between statins. The TRIG lowering effect of these agents is greater in patients starting with a higher baseline TRIG level. The percentage of TRIG lowering is the same percentage as the drug's LDL lowering. ** A recent New England Journal of Medicine review (12 Aug 99) stated "...patients with severe hypertriglyceridemia are best treated with diet and a fibrate, alone or in combination with nicotinic acid, n-3 fatty acids, possibly a statin...."

4) If elevated TRIG are a problem, there are other drugs that should be considered first line therapies. These include the niacin and the fibric acid derivatives [ex. gemfibrozil, fenofibrate]. Their effects on TRIG are much more pronounced that the statins.

5) A recent change to Baycol®'s product insert make the concurrent use of cerivastatin and a fibrate (ex. gemfibrozil) a CONTRAINDICATION because of a slightly greater incidence of rhabdomyolysis.

** Stein et al. Am J Cardiol 1998;81(4A):66B-69B.

This Pearl is meant for academic and educational purposes only. This Pearl is meant to raise important points regarding the safe and cost-effective pharmacotherapy of patients. It is not meant to be the definitive reference for the treatment or prophylaxis of various diseases. Although every effort is taken to ensure this Pearl is correct and factual, errors may occur. The Pharmacoeconomic Center assumes no liability for incorrect information or harm that may occur from the use of the information included in this Pearl.