Using more than one cholesterol drug

Your doctor may feel it is beneficial for you to take more than one cholesterol drug, especially if you have:

• Metabolic syndrome -- this is when you have several risk factors for heart disease, including elevated triglycerides, low HDL, poor handling of blood glucose (sugar), and abdominal obesity (excessive weight concentrated in the abdominal area)
• Inherited cholesterol imbalances -- also called familial hypercholesterolemias, these are characterized by extremely high levels of one or more components of the lipid profile, with high cholesterol often starting at a young age

Statin combinations

Statins, for example, are widely used as first-choice drugs to lower LDL cholesterol. They also can help raise HDL cholesterol somewhat.

Because fibrates focus more on lowering triglycerides and VLDL cholesterol, while raising HDL, statins and fibrates are sometimes used together for maximum effect. However, using medications in combination may increase the chances for side effects and serious complications. For instance, when statins are combined with fibrates, particularly with gemfibrozil, there is an increase risk for rhabdomyolysis. This is a serious condition that causes muscle pain and, in rare cases, can lead to kidney failure. Fatalities associated with rhabdomyolysis occurred with the statin cerivastatin (Baycol), especially at high doses and in combination with fibrates. This statin was withdrawn from the market in 2001. Combining a statin with fenofibrate (Antara, Lofibra, Tricor, Triglide) may be less likely to cause side effects. Nevertheless, you should consult a specialist in lipid management before using a statin-fibrate combination.

Nicotinic acid (niacin) is also used to raise HDL and to lower non-HDL cholesterol. Many clinical studies have now been done using combinations of a statin and niacin. The statin is responsible for most of the LDL lowering. Adding niacin improves the rest of the lipid profile. Adding niacin, however, can increase side effects. The most common side effects include flushing, itching, and elevated blood sugar.

The U.S. Food and Drug Administration has approved some single tablet statin combination medications:

• Advicor -- a combination of niacin and lovastatin
• Vytorin -- a combination of ezetimibe and simvastatin
• Caduet -- a combination of atorvastatin and a calcium channel blocker

References

Vega GL. Management of atherogenic dyslipidemia of the metabolic syndrome: evolving rationale for combined drug therapy. Endocrinol Metab Clin North Am. 2004 Sep;33(3):525-544.

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