1. Step 3 P-treatment: Drug Class Selection

2. Pharmacological and Non-Pharmacological Management

3. Drug Classes

4. MOA • HMG-CoAreductase inhibitor : reduces hepatic cholesterol synthesis • Efficacy (++++) • Significant reduction of LDL (up to 35%) • Increase in HDL (5-10 %) • Decreased triglyceride levels • Level of evidence: meta analysis

5. Safety: (+++) • Risk of myositis if taken in combination with fibrates or niacin • Not recommended in those with hepatic derangements • Suitability (+++) • Primary concern is LDL lowering • Ease of administration: oral preparation, once a day. • Cost: (++++) • Afordel: Php 203.25/ month at 10 mg/day

6. MOA • Reduces production of VLDL: secondary reduction in LDL and increase in HDL • Efficacy (+++) • Significant increase in HDL (~30%) • Decrease in LDL (~20%) • Significant decrease in Triglycerides • Long experience: reduction in coronary events and mortality

7. Nicotinic Acid- Continued • Safety (++) • Intolerance is common with full doses • “hot flashes” and pruritus • Precaution if used with statins • Suitability (++) • Suboptimal LDL lowering if not at full dose • Cost (+++) • Niaspan: Php 555 pesos / month at 500 mg/day

8. MOA • PPAR-alpha agonist • Reduced Apolipoprotein C-III synthesis: increased lipoprotein lipase activity: increased VLDL clearance • Efficacy (++) • Significantly reduces triglycerides (~40%) • Increase HDL (~20%) • Reduce LDL (~15%) • Reduced CHD rates among hypercholesterolemics

9. Safety (++) • Risk of developing cholelithiasis, hepatitis, and myositis • Suitability (++) • Most benefit is seen among those with hypertriglyceridemia and low HDL cholesterol • Taken twice a day • Cost (++) • Nubrex: Php 1072 / month at 200 mg/day

10. MOA • Reduces enterohepatic circulation of bile acids • Increases hepatic production of bile acids, consuming hepatic cholesterol • Efficacy (+++) • Reducton in LDL (~20%) • Increase in triglycerides • No effect to HDL • Reduced incidence of coronary events in studies

11. BAB Resins- Continued • Safety (+++) • Interferes with absorption of fat-soluble vitamins • Caution with warfarin • Suitability (++) • Primary effect targets LDL • Monotherapy may be insufficient • Doses need to be divided • Cost N/A • Cost abroad is greater than that of statins

12. MOA • Inhibits a cholesterol transporter in the intestine, reducing enteric absorption • Efficacy (+++) • Reduces LDL (~20%) • No significant effect on HDL and Triglycerides

13. Safety (++) • Can be used in combination with statins • Suitability (++) • Specific for LDL reduction • Monotherapy may be insufficient • Once a day dosing • Cost (+) • Ezetrol: Php 3000/month at 10 mg/day

14. Summary Therefore, considering the efficacy, safety and suitability and the cost of the available treatment options, STATINSis the most preferred drug class of choice. Statinsare composed of several kinds, and thus we discuss this further.

15. Drug class of most benefit Statins

16. Locally Available Statins

17. Quick Info for the Different Statins All are 100% synthetic. ** Lovastatin, example of a fungus-derived stain. Not available in the Philippines.

18. Summary Therefore, SIMVASTATIN is the best option among the statins option.

19. Prescription Writing Step 4

20. Date: November 17, 2010 62 Female A.Dionisia Simvastatin, 40 mg tablet 30 Inomin 1x tuwinggabi. Dr. Manny Kalayaan 123456

21. Manny Kalayaan, MD, FPCP, FPMID Philippine General Hospital Mon-Friday 9am to 4pm 0917-12345678 Patient: AD Date:November 17, 2010 Address: Manila Age/Sex: 62/F R/ Simvastatin40 mg tablet#30 Sig: Inomin 1 tablet sagabi Dr. Manny Kalayaan Lic. No.123456