INDICATIONS AND USAGE
Therapy with ALTOPREV® lovastatin extended-release tablets should be a component of multiple risk factor intervention in those individuals with dyslipidemia who are at risk for atherosclerotic vascular disease. ALTOPREV® 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.
ALTOPREV®
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, ALTOPREV® is indicated to reduce the risk of:
- Myocardial infarction
- Unstable angina
- Coronary revascularization procedures
(See CLINICAL PHARMACOLOGY, Clinical Studies.)
Coronary Heart Disease
ALTOPREV® 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.
Hyperlipidemia
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.
ALTOPREV® is indicated as an adjunct to diet for the reduction of elevated Total-C, LDL-C, Apo B, and TG, and to increase HDL-C in patients with primary hypercholesterolemia (heterozygous familial and non-familial) and mixed dyslipidemia (Fredrickson types IIa and IIb, see Table VI) when the response to diet restricted in saturated fat and cholesterol and to other non-pharmacological measures alone has been inadequate.
General Recommendations
Prior to initiating therapy with ALTOPREV®, 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 x (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, ALTOPREV® is not indicated.
The National Cholesterol Education Program (NCEP) Treatment Guidelines are summarized below:
Table V NCEP Treatment Guidelines: LDL-C Goals and Cutpoints for Therapeutic Lifestyle Changes and Drug Therapy in Different Risk Categories |
† CHD, coronary heart disease
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†† Some authorities recommend use of LDL-lowering drugs in this category if an LDL-C level of <100mg/dL cannot be achieved by therapeutic lifestyle changes.
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Others prefer use of drugs that primarily modify triglycerides and HDL-C, e.g., nicotinic acid or fibrate. Clinical judgement also may call for deferring drug therapy in this subcategory.
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††† Almost all people with 0-1 risk factor have 10-year risk <10%; thus, 10-year risk assessment in people with 0-1 risk factor is not necessary.
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| 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) |
After the LDL-C goal has been achieved, if the TG is still ≥200 mg/dL, non-HDL-C (Total-C minus HDL-C) 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 LDLC levels are not available, should the Total-C be used to monitor therapy.
Although ALTOPREV® 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). [See Table VI ]
Table VI Classification of Hyperlipoproteinemias |
TC = total cholesterol; TG = triglycerides; LDL = low-density lipoprotein;
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VLDL = very low-density lipoprotein; IDL = intermediate-density lipoprotein
↑→ = increased or no change
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| | Lipid Elevations |
| Type | Lipoproteins Elevated | Major | Minor |
| I (rare) | Chylomicrons | TG | ↑→TC |
| II a | LDL | TC | - |
| IIb | LDL,VLDL | TC | TG |
| III (rare) | IDL | TC/TG | - |
| IV | VLDL | TG | ↑→TC |
| V (rare) | Chylomicrons, VLDL | TG | ↑→TC |
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