Management of Dyslipidaemias: The Potential Role of Atorvastatin
Michelle I. Wilde
Caroline M. Spencer
Dyslipidaemias, particularly elevated serum low density lipoprotein (LDL) cholesterol levels and low levels of high density lipoprotein (HDL) cholesterol, are major risk factors for the development of atherosclerosis and subsequent coronary heart disease (CHD). It is well accepted that reducing total cholesterol and LDL-cholesterol levels, regardless of the intervention used, can significantly reduce the risk of CHD morbidity and mortality. Once a dyslipidaemia has been identified, secondary causes should be identified and treated, where possible, and other risk factors for CHD managed. Nonpharmacological interventions (including diet and lifestyle modifications) are the first step in the management of all patients with dyslipidaemia. If target serum lipid levels are not achieved after 3 to 6 months of nonpharmacological intervention (or <=3 months in those with CHD), drug therapy may be considered. The main drug classes available for the treatment of dyslipidaemia are the 3-hydroxy-3-methylglutaryl-coenzyme-A (HMG-CoA) reductase inhibitors (`statins'), fibric acid derivatives, bile acid sequestrants and nicotinic acid. Probucol may be used in selected patients. Treatment choices are influenced by the presence of established CHD or risk factors for CHD and the type and severity of dyslipidaemia. Atorvastatin has greater LDL-cholesterol-lowering activity than other members of its class; it also has greater triglyceride-lowering properties. Atorvastatin appears to have a similar tolerability profile to other HMG-CoA reductase inhibitors; however, longer term tolerability data are required. Available evidence from modelling studies or economic assessments of clinical trial data suggests that atorvastatin is more cost-effective than other HMG-CoA reductase inhibitors in terms of cost per unit of cholesterol lowering achieved; confirmatory data are required. Thus, on the basis of the available evidence, atorvastatin represents a first-line treatment option for patients with diet-resistant primary hypercholesterolaemia. Whether this agent has beneficial effects on coronary morbidity, mortality and/or total mortality, as confirmed for some other HMG-CoA reductase inhibitors, is currently being determined. The marked LDL-cholesterol-lowering activity of atorvastatin may make this drug particularly suitable for patients with heterozygous familial hypercholesterolaemia; it may be used alone or as an adjunct to other lipid-lowering treatments in patients with homozygous familial hypercholesterolaemia. Atorvastatin also appears to be an appropriate treatment for patients with combined hyperlipidaemia.
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