Evaluate the need for NON-statins

Continue to use a statin first in most patients. Save omega-3s or fibrates for triglyceride levels ≥ 500 mg/dL or even approaching 1000 mg/dL...
Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition

As a hospital pharmacist, you will continue to see LESS use of non-statins (niacin, etc) for dyslipidemia due to limited evidence of CV benefit. Consider discontinuing non-statins when patients are admitted if there's no good reason for the patient to be on them. Use these tips to evaluate the need for non-statins...

Save non-statin ADD-ONs for secondary prevention in patients who can't tolerate a high-intensity statin like atorvastatin (Lipitor, Ator) 80 mg, or those who don't get the expected percent LDL-lowering from a statin. Consider ezetimibe (Choletimb, Cholstop) if a non-statin add-on is needed. There's one fewer CV event for every 50 acute coronary syndrome patients treated with simvastatin (Zocor) plus ezetimibe for 7 years compared to simvastatin alone.

There's no good evidence that adding bile acid sequestrants, fibrates, niacin, or omega-3 fatty acids improves CV outcomes. Reserve non-statin MONOtherapy for secondary prevention patients who can't use a statin or possibly those with VERY high triglycerides. In these patients, consider a bile acid sequestrant, gemfibrozil, or niacin. These seem to reduce CV events when used alone. Lean toward a bile acid sequestrant like cholestyramine (Questran, Cholestran, Quantamash) for high LDL and gemfibrozil (Lopid, Cholenorm, Fibropid) for high triglycerides and low HDL. Be careful with niacin due to increased glucose, muscle pain, liver toxicity, etc.

For high triglycerides, emphasize lifestyle changes and good diabetes control. Continue to use a statin first in most patients. Save omega-3s or fibrates for triglyceride levels ≥ 500 mg/dL or even approaching 1000 mg/dL. There's no reliable evidence that lowering triglycerides reduces CV events or prevents pancreatitis. Continue to evaluate statin adherence and tolerability when patients are hospitalized. For statin muscle pain, consider a lower dose, changing to a different statin or possibly alternate-day dosing.

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