How long do you continue drug therapy?

[Old Timer]

Case One: approx 45 y/o wm with total cholesterol of 240 LDL of 120 HDL of 35. Past family history notable for fatal MI father (39) and paternal grandmother (52). Fails a trial of lifestyle changes. MD implements Lipitor 10mg/day increasing to 20mg/day. Total Cholsterol falls to 142 LDL to 86. Patient changes life style and loses 20 lbs. Total Cholesterol 126 with LDL of 66. The question is: Do you withdraw the statin? Is there any advantage to statins for primary prevention?


Case Two: 50 Y/O BM with BMI of 26 and FBS of 160. Controlled by Metformin & Glipizide. After lifestyle changes and weight loss BMI of 22, FBS returns to normal. Do you continue drug treatment?

It seems to me the pharmaceutical industrial complex wants people on meds for chronic conditions forever. When do you do a trial w/o drugs if other conditions have changed that may render the need for drug therpay moot?

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[apteryx]

Well, how many fatasses do you know who actually stop eating $2.99 McRibs and chinese buffets? If the lifestyle changes, I don't know why you would want to keep them on lipitor other than for making money. Isn't it the prescriber's job to follow up and say "yeah, guess you don't need this anymore"?

Is lipitor still the number 1 drug in the US? My top 200 list is from 2008.

 

[rph3664]

I wouldn't withdraw drug therapy completely, but reduce the dose and see if the patient remains stabilized.

 

[CUpharmD2013]

I wouldn't withdraw drug therapy completely, but reduce the dose and see if the patient remains stabilized.

I'm just a lowly student, but....I agree with this. As the pharmacist you can encourage the patient to have this discussion with their doctor, but I think it's the doctor's decision in the end. Obviously, you also want to remind the patient that if they lower the dose or go off the medication all together, that they need to continue their healthy lifestyle because it can come back. Also, in relation to the patient with family history, were these outcomes due to poor lifestyle or genetic predispositions? A patient that is genetically predisposed to hyperlipidemia may need to be on medication for life in order to keep things under control. It could be possible that they could survive on one of the generic statins until Lipitor comes off patent in the near future.

 

[rph3664]

2013, you do need to know that in most cases, the pharmacist has essentially no input into drug therapy.

 

[VA Hopeful Dr]

Case One: approx 45 y/o wm with total cholesterol of 240 LDL of 120 HDL of 35. Past family history notable for fatal MI father (39) and paternal grandmother (52). Fails a trial of lifestyle changes. MD implements Lipitor 10mg/day increasing to 20mg/day. Total Cholsterol falls to 142 LDL to 86. Patient changes life style and loses 20 lbs. Total Cholesterol 126 with LDL of 66. The question is: Do you withdraw the statin? Is there any advantage to statins for primary prevention?


Case Two: 50 Y/O BM with BMI of 26 and FBS of 160. Controlled by Metformin & Glipizide. After lifestyle changes and weight loss BMI of 22, FBS returns to normal. Do you continue drug treatment?

It seems to me the pharmaceutical industrial complex wants people on meds for chronic conditions forever. When do you do a trial w/o drugs if other conditions have changed that may render the need for drug therpay moot?

Case one - depends who you ask (cardiologist v. everyone else). Given the family history and the anti-inflammatory aspect of statins, I likely wouldn't stop therapy. Minus the family history, I'd start to taper the lipitor and see what happens. Also, what did the HDL do during this time?

Case two - taper the meds and watch. I'd feel tons better about getting a diabetic off of their meds than an at-risk MI patient. I've gotten patients off of insulin (though rarely) so I wouldn't see the problem with d/c'ing the orals other than I've never seen it able to happen before.

 

[spacecowgirl]

Case one - depends who you ask (cardiologist v. everyone else). Given the family history and the anti-inflammatory aspect of statins, I likely wouldn't stop therapy. Minus the family history, I'd start to taper the lipitor and see what happens. Also, what did the HDL do during this time?

I agree with this. Statins do more than just lower LDL.

In case 2 I would try to taper or d/c the sulfonylurea and see what happens with just metformin as his insulin resistance has probably been long standing. To me the risk:benefit of metformin is pretty low, esp compared to other DM drugs.

 

[Praziquantel86]

Case One: approx 45 y/o wm with total cholesterol of 240 LDL of 120 HDL of 35. Past family history notable for fatal MI father (39) and paternal grandmother (52). Fails a trial of lifestyle changes. MD implements Lipitor 10mg/day increasing to 20mg/day. Total Cholsterol falls to 142 LDL to 86. Patient changes life style and loses 20 lbs. Total Cholesterol 126 with LDL of 66. The question is: Do you withdraw the statin? Is there any advantage to statins for primary prevention?

This one is a tough call. The effect of lifestyle modifications on cholesterol is very unpredictable, and based on my (limited) experience, this degree of weight loss won't have that large an effect. I'd like to know what other issues this person may have (smoker? hypertensive?), but given the family history I'd be pretty reluctant to remove the statin altogether. A dose decrease may be beneficial, followed by at least a few months of watchful waiting.

Case Two: 50 Y/O BM with BMI of 26 and FBS of 160. Controlled by Metformin & Glipizide. After lifestyle changes and weight loss BMI of 22, FBS returns to normal. Do you continue drug treatment?

I think this one is a little more clear-cut. I would taper the glipizide off first, and see what happens. If FBS and A1C remain normal, then go ahead and start cutting out the metformin. As far as I know, the only drug with proven mortality benefit (beyond that provided by glucose lowering) is metformin, and that is only in patient's with elevated glucose levels. I don't see a benefit in continuing indefinitely.

It seems to me the pharmaceutical industrial complex wants people on meds for chronic conditions forever. When do you do a trial w/o drugs if other conditions have changed that may render the need for drug therpay moot?

I think the best example of this would be OI prophylaxis in HIV patients. You have a defined threshold of CD4+ count for a certain duration of time for certain medications, and you remove prophylaxis. You'll see similar things with post-DVT treatment periods, post-stent Plavix duration, but the treatment lengths are a little fuzzier.

In most cases, the decision to withdraw therapy isn't clear-cut. A lot of judgment and experience goes into that, with a lot of specific longitudinal information about the patient. I'd argue that's the reason we receive a comprehensive education rather than a bunch of guideline handouts and flowcharts.

 

[Ackj]

I'd say keep the statin, although maybe lowering to 10mg could work if you really wanted to. There are many more benefits than just cholesterol, especially in a patient with family history of MI. Effects on CRP, plaque stability, increased nitric oxide...



Diet and weight loss is probably enough to remove the glipizide and keep an eye on accuchek and a1c. You might have to keep the metformin because of decreased insulin sensitivity, don't know if you would be able to get that back with lifestyle changes, but doesn't seem probable.

 

[Old Timer]

RE: Statins. I can't find anything on statins for primary prevention. Do you guys have any info?

 

[owlegrad]

RE: Statins. I can't find anything on statins for primary prevention. Do you guys have any info?

Try the JUPITOR trail.

 

[Old Timer]

Try the JUPITOR trail.

I'll see if I can find out what the CRP levels were...

 

[gmuskie]

RE: Statins. I can't find anything on statins for primary prevention. Do you guys have any info?

Alot of the primary prevention studies were the ones done earlier on with statins. I would say relevant to this case would be ASCOT-LLA because he does have the family history risk factors that would warrant primary prevention statin..

I would say keep him on the statin ...the family history and just not knowing what kind of buildup has occured while the cholesterol was high..try to keep everything stable.

 

[spacecowgirl]

RE: Statins. I can't find anything on statins for primary prevention. Do you guys have any info?

AFCAPS, WOS, ASCOT-LLA, JUPITER, CARDS (for pts with DM)

 

[Quiksilver]

This one is a tough call. The effect of lifestyle modifications on cholesterol is very unpredictable, and based on my (limited) experience, this degree of weight loss won't have that large an effect. I'd like to know what other issues this person may have (smoker? hypertensive?), but given the family history I'd be pretty reluctant to remove the statin altogether. A dose decrease may be beneficial, followed by at least a few months of watchful waiting.




I think this one is a little more clear-cut. I would taper the glipizide off first, and see what happens. If FBS and A1C remain normal, then go ahead and start cutting out the metformin. As far as I know, the only drug with proven mortality benefit (beyond that provided by glucose lowering) is metformin, and that is only in patient's with elevated glucose levels. I don't see a benefit in continuing indefinitely.



I think the best example of this would be OI prophylaxis in HIV patients. You have a defined threshold of CD4+ count for a certain duration of time for certain medications, and you remove prophylaxis. You'll see similar things with post-DVT treatment periods, post-stent Plavix duration, but the treatment lengths are a little fuzzier.

In most cases, the decision to withdraw therapy isn't clear-cut. A lot of judgment and experience goes into that, with a lot of specific longitudinal information about the patient. I'd argue that's the reason we receive a comprehensive education rather than a bunch of guideline handouts and flowcharts.

I agree with this

 

[Sparda29]