Is ezetimibe/simvastatin no better than simvastatin alone? Lessons learned and clinical implications

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Ezetimibe, however, lowers LDL-C by an ultimate mechanism similar to that of statins and bile acid sequestrants, ie, by up-regulating LDL receptors, although these drugs reach this mechanism via different pathways. Statins inhibit cholesterol synthesis, thereby lowering hepatic intracellular cholesterol and thus up-regulating LDL-receptors and enhancing LDL-C clearance from the plasma. Bile acid sequestrants interrupt bile acid reabsorption in the ileum, thereby decreasing intracellular hepatic cholesterol and up-regulating LDL receptors. Ezetimibe, like bile acid sequestrants, also decreases cholesterol return to the liver, lowering hepatic intracellular levels and thus up-regulating LDL receptors. 18

Ezetimibe is unlikely to have an off-target effect because it is only fractionally absorbed systemically, and a recent animal study showed that it enhances macrophage efflux of cholesterol, thereby potentially increasing reverse cholesterol transport. 19 Ezetimibe has also been shown to reduce atherosclerosis in animal models. 20

In their editorial, Drs. Brown and Taylor 7 noted that ezetimibe reduces the expression of adenosine triphosphate binding cassette A1 (ABCA1) in Caco-2 (an intestinal cell line), and this may be an example of an off-target effect. However, statins also reduce ABCA1 expression in macrophages. 21 ABCA1 is sensitive to intracellular cholesterol, and when cholesterol levels are decreased, whether by statins or by ezetimibe, ABCA1 expression is down-regulated. 22

Theory 2: Intima-media thickness does not reflect the true benefits of lowering LDL-C

The carotid intima-media thickness is a surrogate end point that predicts coronary events and the rate of progression of coronary atherosclerosis. 23 In trials of lovastatin (Mevacor), 24 pravastatin (Pravachol), 25 and rosuvastatin (Crestor), 26 the carotid intima-media was thinner at 24 months with the active drug than with placebo. In two relatively small trials—ARBITER 1 (n = 161), 27 which was open-label, and ASAP (n = 325) 28,29—aggressive lipid-lowering reduced the progression of intima-media thickness better than less-aggressive therapy. However, this measure has been used to evaluate the effects of differing degrees of LDL-C reduction between active treatments in fewer than 500 research participants.

Furthermore, what part or parts of the carotid system are we talking about? In recent trials led by Dr. Kastelein, the intima-media thickness of the common carotid arteries increased with pactimibe (an acyl-coenzyme A:cholesterol O-acyltransferase, or ACAT, inhibitor) 30 and torcetrapib, 31 but the six-site composite measure (which was the primary end point in these trials, as in ENHANCE) did not increase more than in the control groups. Pactimibe was also shown to increase atheroma volume as measured by intravascular ultrasonography in the ACTIVATE trial. 32 Therefore, the thickness of the common carotid arteries has been shown to be a better predictor of harm from a therapy than the composite measurement.

The advantage of measuring the common carotid artery is that it is easier to visualize and measure, and therefore the measurements vary less. In the METEOR trial, 26 the six-site measurement increased significantly less with rosuvastatin than with placebo, but the common carotid measurement alone was more strongly associated with a difference in progression. In the ENHANCE trial, the thickness of the common carotid arteries increased by 0.0024 mm with simvastatin alone vs 0.0019 mm with simvastatin/ezetimibe, a difference of 0.005 mm that was not statistically significant ( P = .93). 1

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