"April 2, 2010 â€“ Should healthy people take a cholesterol-lowering drug to prevent heart disease even if they don't have high cholesterol?
The answer, for some people, is yes. It's a controversial answer that raises a lot of questions. H"...
Therapy with MEVACOR should be a component of multiple risk factor intervention in those individuals with dyslipidemia at risk for atherosclerotic vascular disease. MEVACOR should be used in addition to a diet restricted in saturated fat and cholesterol as part of a treatment strategy to lower total-C and LDL-C to target levels when the response to diet and other nonpharmacological measures alone has been inadequate to reduce risk.
Primary Prevention of Coronary Heart Disease
In individuals without symptomatic cardiovascular disease, average to moderately elevated total-C and LDL-C, and below average HDL-C, MEVACOR is indicated to reduce the risk of:
- Myocardial infarction
- Unstable angina
- Coronary revascularization procedures (See CLINICAL PHARMACOLOGY, Clinical Studies.)
Coronary Heart Disease
MEVACOR is indicated to slow the progression of coronary atherosclerosis in patients with coronary heart disease as part of a treatment strategy to lower total-C and LDL-C to target levels.
Therapy with lipid-altering agents should be a component of multiple risk factor intervention in those individuals at significantly increased risk for atherosclerotic vascular disease due to hypercholesterolemia. MEVACOR is indicated as an adjunct to diet for the reduction of elevated total-C and LDL-C levels in patients with primary hypercholesterolemia (Types IIa and IIb2), when the response to diet restricted in saturated fat and cholesterol and to other nonpharmacological measures alone has been inadequate.
Adolescent Patients with Heterozygous Familial Hypercholesterolemia
MEVACOR is indicated as an adjunct to diet to reduce total-C, LDL-C and apolipoprotein B levels in adolescent boys and girls who are at least one year post-menarche, 10-17 years of age, with heFH if after an adequate trial of diet therapy the following findings are present:
1. LDL-C remains > 189 mg/dL or
|Type||Lipoproteins elevated||Lipid Elevations|
|I Ib||LDL, VLDL||C||TG|
|V (rare)||chylomicrons, VLDL||TG||↑→C|
|IDL = intermediate-density lipoprotein.|
2. LDL-C remains > 160 mg/dL and:
- there is a positive family history of premature cardiovascular disease or
- two or more other CVD risk factors are present in the adolescent patient
Prior to initiating therapy with lovastatin, secondary causes for hypercholesterolemia (e.g., poorly controlled diabetes mellitus, hypothyroidism, nephrotic syndrome, dysproteinemias, obstructive liver disease, other drug therapy, alcoholism) should be excluded, and a lipid profile performed to measure total-C, HDL-C, and TG. For patients with TG less than 400 mg/dL ( < 4.5 mmol/L), LDL-C can be estimated using the following equation:
LDL-C = total-C – [0.2 × (TG) + HDL-C]
For TG levels > 400 mg/dL ( > 4.5 mmol/L), this equation is less accurate and LDL-C concentrations should be determined by ultracentrifugation. In hypertriglyceridemic patients, LDL-C may be low or normal despite elevated total-C. In such cases, MEVACOR is not indicated.
The National Cholesterol Education Program (NCEP) Treatment Guidelines are summarized below:
NCEP Treatment Guidelines: LDL-C Goals and Cutpoints
for Therapeutic Lifestyle Changes and Drug Therapy in Different Risk Categories
|Risk Category||LDL Goal (mg/dL)||LDL Level at Which to Initiate Therapeutic Lifestyle Changes (mg/dL)||LDL Level at Which to Consider Drug Therapy (mg/dL)|
|CHD* or CHD risk equivalents (10-year risk > 20%)||< 100||≥ 100||≥ 130 (100-129: drug optional††|
|2+ Risk factors (10 year risk ≤ 20%)||< 130||≥ 130||10-year risk 10-20%: ≥ 130 10-year risk < 10%: ≥ 160|
|0-1 Risk factor†††||< 160||≥ 160||>190 (160-189: LDL-lowering drug optional)|
|† CHD, coronary heart disease
†† Some authorities recommend use of LDL-lowering drugs in this category if an LDL-C level of < 100 mg/dL cannot be achieved by therapeutic lifestyle changes. Others prefer use of drugs that primarily modify triglycerides and HDL-C, e.g., nicotinic acid or fibrate. Clinical judgment also may call for deferring drug therapy in this subcategory.
††† Almost all people with 0-1 risk factor have a 10-year risk < 10%; thus, 10-year risk assessment in people with 0-1 risk factor is not necessary.
After the LDL-C goal has been achieved, if the TG is still ≥ 200 mg/dL, non-HDL-C (total-C minus HDLC) becomes a secondary target of therapy. Non-HDL-C goals are set 30 mg/dL higher than LDL-C goals for each risk category.
At the time of hospitalization for an acute coronary event, consideration can be given to initiating drug therapy at discharge if the LDL-C is ≥ 130 mg/dL (see NCEP Guidelines above).
Since the goal of treatment is to lower LDL-C, the NCEP recommends that LDL-C levels be used to initiate and assess treatment response. Only if LDL-C levels are not available, should the total-C be used to monitor therapy.
Although MEVACOR may be useful to reduce elevated LDL-C levels in patients with combined hypercholesterolemia and hypertriglyceridemia where hypercholesterolemia is the major abnormality (Type IIb hyperlipoproteinemia), it has not been studied in conditions where the major abnormality is elevation of chylomicrons, VLDL or IDL (i.e., hyperlipoproteinemia types I, III, IV, or V).2 The NCEP classification of cholesterol levels in pediatric patients with a familial history of hypercholesterolemia or premature cardiovascular disease is summarized below:
|Category||Total-C (mg/dL)||LDL-C (mg/dL)|
|Acceptable||< 170||< 110|
|High||≥ 200||≥ 130|
Children treated with lovastatin in adolescence should be re-evaluated in adulthood and appropriate changes made to their cholesterol-lowering regimen to achieve adult goals for LDL-C.
DOSAGE AND ADMINISTRATION
The patient should be placed on a standard cholesterol-lowering diet before receiving MEVACOR and should continue on this diet during treatment with MEVACOR (see NCEP Treatment Guidelines for details on dietary therapy). MEVACOR should be given with meals.
The usual recommended starting dose is 20 mg once a day given with the evening meal. The recommended dosing range of lovastatin is 10-80 mg/day in single or two divided doses; the maximum recommended dose is 80 mg/day. Doses should be individualized according to the recommended goal of therapy (see NCEP Guidelines and CLINICAL PHARMACOLOGY). Patients requiring reductions in LDLC of 20% or more to achieve their goal (see INDICATIONS AND USAGE) should be started on 20 mg/day of MEVACOR. A starting dose of 10 mg of lovastatin may be considered for patients requiring smaller reductions. Adjustments should be made at intervals of 4 weeks or more. The 10 mg dosage is provided for information purposes only. Although lovastatin tablets 10 mg are available in the marketplace, MEVACOR is no longer marketed in the 10 mg strength.
Cholesterol levels should be monitored periodically and consideration should be given to reducing the dosage of MEVACOR if cholesterol levels fall significantly below the targeted range.
Dosage in Patients taking Danazol, Diltiazem, Dronedarone or Verapamil
In patients taking danazol, diltiazem, dronedarone or verapamil concomitantly with lovastatin, therapy should begin with 10 mg of lovastatin and should not exceed 20 mg/day (see CLINICAL PHARMACOLOGY, Pharmacokinetics, WARNINGS, Myopathy/Rhabdomyolysis, PRECAUTIONS: DRUG INTERACTIONS, Other Drug Interactions).
Dosage in Patients taking Amiodarone
Adolescent Patients (10-17 years of age) with Heterozygous Familial Hypercholesterolemia
The recommended dosing range of lovastatin is 10-40 mg/day; the maximum recommended dose is 40 mg/day. Doses should be individualized according to the recommended goal of therapy (see NCEP Pediatric Panel Guidelines4, CLINICAL PHARMACOLOGY, and INDICATIONS AND USAGE). Patients requiring reductions in LDL-C of 20% or more to achieve their goal should be started on 20 mg/day of MEVACOR. A starting dose of 10 mg of lovastatin may be considered for patients requiring smaller reductions. Adjustments should be made at intervals of 4 weeks or more.
Concomitant Lipid-Lowering Therapy
Dosage in Patients with Renal Insufficiency
In patients with severe renal insufficiency (creatinine clearance < 30 mL/min), dosage increases above 20 mg/day should be carefully considered and, if deemed necessary, implemented cautiously (see CLINICAL PHARMACOLOGY and WARNINGS, Myopathy/Rhabdomyolysis).
No. 8123 — Tablets MEVACOR 20 mg are blue, octagonal tablets, coded MSD 731 on one side and plain on the other. They are supplied as follows:
NDC 0006-0731-61 unit of use bottles of 60.
No. 8124 — Tablets MEVACOR 40 mg are green, octagonal tablets, coded MSD 732 on one side and plain on the other. They are supplied as follows:
NDC 0006-0732-61 unit of use bottles of 60.
Store at 20-25°C (68-77°F). [See USP Controlled Room Temperature.] Tablets MEVACOR must be protected from light and stored in a well-closed, light-resistant container.
2 Classification of Hyperlipoproteinemias
4 National Cholesterol Education Program (NCEP): Highlights of the Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Pediatrics. 89(3):495-501. 1992.
By: Mylan Pharmaceuticals Inc. Morgantown, WV 26505, USA OR Mylan Pharmaceuticals ULC, Etobicoke, Ontario, Canada M8Z 2S6. Revised: 10/2012
Last reviewed on RxList: 12/7/2012
This monograph has been modified to include the generic and brand name in many instances.
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