"Ezetimibe combination drug, now key option in dyslipidemia"

An interview on Professor Heo Jung Ho of cardiology division at Kosin University Gospel Hospital

Recommended to prescribe combination therapy on patients with cardiovascular issues

Combination drug shows definite advantage in drug adherence, helps to keep the medication number down

Professor Heo Jung Ho

Statin has been demonstrating outstanding efficacy in low-density lipoprotein cholesterol (LDL-C) level control, while showing an assuring benefit in risk of cardiovascular death.

 

The medicine has surely shifted the paradigm of dyslipidemia management.

 

Nevertheless, there is no perfect drug in this world.

 

Statin also has concerning reports of risk of diabetes and musculoskeletal adverse reactions when using high-dose (high-intensity).

 

Still, the ‘statin plus ezetimibe’ combination is well sought after in the market.

 

Following the current trend in cardiovascular disease treatment—the lower the LDL-C, the better for the benefit in cardiovascular system—the combination drug has taken up a significant share of the pie in dyslipidemia treatment prescription.

 

Even in Korea, many pharmaceutical companies have combined ezetimibe with atorvastatin or rosuvastatin to launch combination drugs.

 

The released drugs have now settled in the market.

 

Daily Pharm interviewed Professor Heo Jung Ho of cardiology division at Kosin University Gospel Hospital to hear about his opinion on the ezetimibe and its efficacy.

 

-Generally, when is ezetimibe combination therapy used?

 

Personally, I still follow the pattern of initiating the prescription from moderate to high-dose statin through high-dose statin.

 

But in some cases, patients cannot reach the recommended LDL-C target level at 70 mg/ dL (Korean guideline), or 55 mg/ dL (U.S.

 

guideline), even with high-dose statin.

 

And this is when I use the ezetimibe combination drug.

 

And for patients seeing musculoskeletal adverse reaction or having high risk in diabetes, the ezetimibe combination therapy could be a good option.

 

-What is your opinion on using the ezetimibe combination therapy as a first-line treatment for dyslipidemia patients?

 

A clinical study in Korea is in process to confirm clear evidences.

 

Currently, Professor Jang Yangsoo at Yonsei University Severance Hospital is leading the head-to-head comparative trial of high-intensity statin and ezetimibe combination therapy in over 3,000 patients with cardiovascular disease in Korea.

 

200 of the participating patients are registered from Kosin University Hospital.

 

The outcome of the study to be disclosed in three years would give us some clearer answers.

 

Personally, I expect both of the groups would demonstrate clinically meaningful result and efficacy.

 

-Between rosuvastatin and atorvasutatin, what are some circumstances to be considered when prescribing a combination therapy?

 

There is no big difference between the two.

 

But some patients prefer either ‘atorvastatin plus ezetimibe’ or ‘rosuvastatin plus ezetimibe.’ In such case, I base my decision on clinical evidences.

 

The effects of 20 mg of rosuvastatin and 40 mg of atrovasutatin are on par, but the combination that noticeably lowers LDL-C level would be used.

 

-Do you prefer to use a combination drug for ezetimibe combination therapy?

 

First of all, the combination drug is obviously more convenient.

 

The medication convenience along with adherence is high.

 

Patients these days ask many questions and research more information online when the number of drugs goes up.

 

A combination drug is easy to explain how the effect is better with the same amount of drugs, and the patients also comply with the medication well.

 

Moreover, the price of combination drug in Korea is comparatively lower against in other countries.

 

As chronic disease patients are sensitive to the cost, the healthcare system in Korea has also boosted the preference in combination drug.

 

- The Korean dyslipidemia treatment guideline recommends ezetimibe therapy as a second-line therapy.

 

Although the U.S.

 

and Europe recommends LDL-C level in the said ultra high risk group to be lowered to 55 mg/ dL and 40 mg/ dL, respectively, Korea recommends the level to be lowered to 70 mg/ dL. The bottom line is that I agree with the slogan of ‘the lower LDL-C is the better.’ However, it is not the absolute rule to be followed.

 

I personally treat patients targeting LDL-C level at 70 mg/ dL at the moment.

 

But when the patients show risk factors like acute coronary syndrome (ACS), myocardial infarction (MI) or peripheral artery disease (PAD), the target level is lowered to 55 mg/ dL.

 

These patients should be more aggressive in lowering the LDL-C level.

 

And if their level does not respond with ezetimibe, Proprotein convertase subtilisin/ kexin type 9 (PCSK-9) inhibitor is prescribed to breakthrough.

 

According to the healthcare reimbursement standard, ezetimibe has to be prescribed as prerequisite.

 

And this is one of the factors raising the prescription rate of combination drug.