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Australian Journal of Pharmacy : April 2005
cholesterol management Taking supplements before heart surgery improves post- operative prospects ering treatment, it is important to encour- age patients to achieve low target choles- terol levels, by combining lifestyle changes with optimal dosing of cholesterol-lower- ing treatment,’ Dr Kritharides said. New agent helps compliance H EART surgery patients appeared to benefit from pre- operative metabolic, physical and mental therapy (MPM) program. Results from a 2003 study on 16 high-risk patients at Melbourne’s Alfred hospital showed reduced oxidative stress and improved quality of life one month after surgery, with the hospital stay shortened by one day in MPM-treated patients. For two or more weeks preceding cardiac surgery, patients received a daily preparation of antioxidants (alpha-lipoic acid, coenzyme Q10 and selenium), magnesium orotate and omega fatty acids. Patients also received exercise training and mental stress reduction therapy. Quality of life assessments and blood measures of lipid peroxidation were made before treatment, immediately before surgery and one month after surgery. The current prospective randomised clinical trial will run at The Alfred for another 18 months. Patients will also be recruited from the Monash Medical Centre and the Austin Hospital. A new hypolipidaemic agent, ezetimibe (Ezetrol) is useful for the small numbers of people who cannot tolerate statins and as an add-on for a larger number who do not reach targets on standard statin therapy. It inhibits cholesterol absorbtion to the intestine and is taken once daily in a10mg tablet. It was PBS listed in August 2004. ‘It lowers cholesterol and appears to do so very safely, however, it is not being pre- scribed very much though there are no tri- als available as to whether the drug improves cardiovascular outcomes. I sus- pect it is the Authority requirement with its inconvenience which is the major barrier. Dr Colquhoun said because it was a new class of drug, it was a good idea for pharmacists to alert patients who devel- oped pain symptoms on statins that this pain could relate to statins and an alter- native treatment was available. ‘For pharmacy the task is to help improve compliance. People can become a bit blasé about statins and we hear and read negative things which are totally out of context, such as associating statins with dementia. ‘It is important for the pharmacist to emphasise to the patient that taking the medication makes a huge difference to pre- venting further heart attacks and strokes.’ A role for complementary medicines ‘Some herbs, vitamins, minerals and food supplements offer a cardioprotective ben- efit, particularly for people with choles- terol levels that are mild-to-moderately elevated,’ said Melbourne pharmacist and naturopath Lesley Braun. ‘Taking a supplement or complemen- tary medicine along with lifestyle inter- ventions are often all that is needed to help keep cholesterol levels acceptable.’ She said there was growing evidence that garlic could have a modifying effect on moderate cholesterol levels with a 250 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 APRIL 2005 mechanism similar to statins ‘insofar as it blocks cholesterol synthesis’. Not any old garlic though. Ms Braun said the level of the active ingredient known as alliin potential—a sulphur com- ponent in the garlic—has to be between 5,000mcg and 6,000mcg to have any effect. In other clinical studies supporting gar- lic, 600mg–900mg of garlic daily has been shown to reduce blood pressure and long- term use appeared to reduce atheroscle- rotic plaque volume, Ms Braun said. There is also promising evidence for policosanol, a substance isolated from waxes found in sugar cane, that appears to have a significant impact on the lipid profile. ‘Clinical trials using 5mg doses of poli- cosanol indicated it could reduce total cho- lesterol levels by up to 15 per cent, reduce HDL cholesterol by up to 18 per cent and reduce LDL levels by 15 per cent. When dosage was increased to 20mg daily the effects were even more dramatic. Total cholesterol levels declined by 23 per cent and HDL levels increased by 31 per cent while LDLlevels were down by 27 per cent.’ Like garlic, policosanol can have a blood-thinning effect and it is best taken with the evening meal, but is generally well tolerated, Lesley Braun said. Nicotinic acid supplements have also been linked to a reduction in cholesterol levels by at least 10 per cent and triglyc- erides by 26 per cent, although one side effect is flushing when high doses are used. Extended release forms are safer and have fewer side effects. Nicotinamide is a related compound but does not alter cho- lesterol levels. There is a slight risk that high does of nicotinic acid may effect liver function but Ms Braun said taking extended dosage meant this was less likely to occur. The recommended daily dose of nico- tinic acid is 1,500 to 3,000mg in a slow release preparation taken at night with food or in divided doses. The extended release form is currently being used together with statin drugs, such as lovastatin and simvastatin, and experi- mental trials are showing good results. s