Combination regimens with statin, niacin, and intestinally active LDL-lowering drugs: alternatives to high-dose statin therapy?

PURPOSE OF REVIEW: To summarize recent studies on combination regimens that employ a statin with added niacin, ezetimibe, and/or bile acid sequestrants, and to understand the implications of these studies for clinical practice. RECENT FINDINGS: Combinations of statin, niacin, and/or intestinally active LDL-lowering drug have demonstrated safety and favorable effects on plasma low and high-density lipoproteins. Niacin and bile acid sequestrants appear to exert beneficial effects on atherosclerotic lesions, whereas results with ezetimibe are uncertain. Moreover, the use of niacin and bile acid sequestrants is supported by clinical outcome results from large monotherapy trials and small combination therapy trials. Three large randomized trials currently are evaluating clinical outcomes with the addition of niacin or ezetimibe to statin treatment. SUMMARY: Until the results of ongoing trials are known, it is reasonable to favor the use of niacin and bile acid sequestrants in combination with statins, based on safety and efficacy with regard to effects on lipoproteins, atherosclerotic lesions, and, to a limited extent, clinical outcomes. The effect of ezetimibe on carotid atherosclerosis is indeterminate, but ezetimibe can be reasonably added to statin therapy as a secondary option for LDL-lowering.

Duke Scholars

Author John Richard Guyton Medicine, Endocrinology, Metabolism, and Nutrition