What is the best initial treatment for elevated LDL-C ?

Edward M. Gardner 5/16/97

Case:
Routine Screening in a 45 y.o. female detects an elevated LDL-C of 205. She has no other CAD risk factors.

Clinical Bottom Lines:

1. Lovastatin is more effective initial treatment than a stepped care regimen (SC)
of cholesterol lowering agents.
2. SC saves money and may be appropriate for the patient who pays out of pocket for prescriptions.

The Evidence:

An open label, intention to treat, RCT of 612 patients with increased cholesterol who received initial tovastatin or a stepped care medical treatment plan for 1 year. SC medications included niacin, bile acid sequestrants, and finally lovastatin.

1. SC increased HDL by 8% vs 1% increase for lovastatin at 1 year.(p<0.001)
2. A subgroup analysis showed that in patients who paid for their prescriptions, decrease in LDL was 19% for SC and 16% for lovastatin.
3. More patients in SC were bothered by side effects, 30%, vs 16% for the lovastatin group.
4. The study tried to approximate conditions of a typical out-patient clinicalpractice.
5. The study was open label.
6. The study was funded by Merck & Co., the makers of lovastatin.

Reference:
Oster G. Borok GM, Menzin J. et al. Cholesterol-Reduction Intervention Study
(CRIS). A randomized trial to assess effectiveness and costs in clinical practice.
Arch Int Med. 1996;156:731-9.