Rx CARE

New cholesterol guidelines enlist pharmacists' help

To all the skeptics saying the latest cholesterol guidelines are pushing too hard toward drug therapy, let the numbers speak for themselves.

Within one year of a heart attack, 25% of men and 38% of women will die, according to the American Heart Association. People who survive a heart attack have a 1.5 to 15 times higher chance of illness and death than the rest of the population. So it is easy to understand the call for more aggressive cholesterol-lowering treatment and better identification for those at high risk for a heart attack, as issued in the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, also known as Adult Treatment Panel (ATP) III.

"I don't think the guidelines are necessarily pushing people toward drug therapy. But given the reluctance of the general population to change their lifestyles, that is where it will end up," remarked Evan Sisson, Pharm.D. He is the diabetes program development coordinator at the McGuire Department of Veterans Affair Medical Center in Richmond, where he also runs a lipid clinic program.

Sisson remarked that one of the exciting things to emerge from the guidelines is the use of the 10-year risk calculator. The reality of a number that will predict risk of a heart attack in 10 years, he said, is going to make getting patients to adhere to cholesterol management a lot easier.

Patients with an absolute 10-year risk of 20% for developing coronary heart disease (CHD) are considered candidates for aggressive therapy, with a treatment goal of LDL levels less than 100 mg/dl. Those with LDL cholesterol of 130 mg/dl or higher, in this high-risk group, are recommended for drug therapy. For the patient who has two or more risk factors with a 10-year risk of less than 10%, drug therapy is recommended at LDL levels of 160 mg/dl or higher, with an LDL goal of 130 mg/dl. For those with no risk factors, or only one, ATP III recommends considering drug therapy at LDL levels of 190 mg/dl, with a goal of 160 mg/dl. Sisson asserted that the statins are considered the drugs of choice for lowering LDL.

After LDL-cholesterol levels are achieved, ATP III recommends the attention be shifted to the triglycerides and focuses specifically on identifying a "metabolic syndrome" of risk factors (e.g., hypertension, elevated triglycerides, low HDL, abdominal obesity) linked to insulin resistance. These often occur together and dramatically increase the risk for coronary events.

Drug therapy, usually including fibrates or nicotinic acid, is indicated after weight reduction and physical activity have failed to lower the triglyceride level below 200 mg/dl.

If the more rigorous guidelines are widely followed, it is estimated that the number of Americans on cholesterol-lowering drugs could triple, from 13 million to 36 million. This presents pharmacists with the opportunity to take a more active role in monitoring therapy and ensuring compliance. The ATP III places great emphasis on adherence and specifically recommends using "the collaborative care of pharmacists."

James McKenney, Pharm.D., strongly advocates a broader involvement of pharmacists, nurses, and dietitians in patient care. McKenney is a professor emeritus of pharmacy at the Virginia Commonwealth University and a member on the National Cholesterol Education Program expert panel.

According to McKenney, studies have proven that if you can empower a nonphysician professional in case management, the results are amazing.

"Pharmacists can do it and do it well," because they have the expertise and can spend more time with the patients, observed McKenney.

Tammy Chernin, R.Ph.

Tammy Chernin. New cholesterol guidelines enlist pharmacists' help.

Drug Topics

2001;11:21.