Atorvastatin Versus Ezetimibe and Fenofibrate as a Lipid-lowering Strategy

It has been demonstrated in several previous primary and secondary studies that lowering low-density lipoprotein cholesterol (LDL-C) with the use of medications such as 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors improves mortality and morbidity related to cardiovascular events in patients with hypercholesterolemia. Such inhibitors, which are known as 'statins', act to block the synthesis of cholesterol in the liver. These medications are generally well tolerated by the vast majority of patients, but a small number experience side effects, most seriously those of myopathies, rhabdomyolysis and elevated liver enzymes - recognition of this fact, that statins are not universally without problems, highlights the need for viable alternatives.

Ezetimibe is a relatively new medication in Canada, approved for use in patients with cholesterol problems. It is an intestinal cholesterol binder that is known to be well-tolerated, with side effects similar to placebo. Alone, it has a modest effect in the lowering of LDL-C. Fenofibrate is a medication that also works through the liver and has long been used to adjust blood lipid levels in patients with mixed lipid problems. Alone it also has a modest effect in the lowering of LDL-C. Recent study, however, has shown that the effect of ezetimibe and fenofibrate together in the lowering of LDL-C is greater than that of either drug alone. This combination, if as effective in this regard as atorvastatin, would prove a valid alternative to the use of the atorvastatin in the lowering of LDL-C, and a benefit for patients who have had problems tolerating statin therapy but still require medication for elevated cholesterol.

Inclusion criteria

-Study is confined to subjects with elevated LDL-C levels 3.0 mmol/L and greater.

Exclusion criteria

• Abnormal liver enzymes (ie, AST, ALT greater than three times the upper limit of normal);
• Creatine kinase levels more than two times the upper limit of normal;
• Uncontrolled ethanol use (this may affect compliance);
• Pregnant or breastfeeding women or women not using adequate contraceptive methods;
• Previous history of intolerance or adverse effects with statins;
• Previous history of intolerance or adverse effects with fibric acid derivatives;
• Previous history of intolerance or adverse effects with ezetimibe;
• Uncontrolled diabetes (HbA1c > 10%);
• Recent myocardial infarction (within 6 weeks);
• Concurrent enrollment in another study.