Statin

Statin

148

statin

statin


statin

statin







statin

LDL-Cholesterol


LDL-Cholesterol
LDL-Cholesterol

Statin

149

statin
1

4 .

10

11

150

Executive Summary
statin

1. LDL-C
( +)

2. ( +)

3. drug interaction
( +)
1. 1 166

2. statin
statin

Statin

151

152

1.
2. statin
3. statin

154

 1

statin
1 (classes of recommendations)
2 (quality and levels of evidence)
3 metabolic syndrome
4 (total cardiovascular risk)
5
6 low density lipoprotein cholesterol (LDL-C)


7
8
1 Statin

9 statin chronic kidney disease (CKD)

Statin

155

 1 (classes of recommendations)(2)

156

++

+/-

 2 (quality and levels of

evidence)(1,2,3)
systematic review
1
randomized-controlled

meta-analysis

2

systematic review
non-randomized controlled
randomized-controlled clinical trial 1
(cohort)
(case control analytic studies)
1

(consensus)
3

Statin

157

 3 metabolic syndrome(4)
3 5

1. (waist circumference)
( > 90 . > 80 .)

2. >130/85 .

3. > 150./.

4. high density lipoprotein cholesteral (HDL-C) < 40./.
< 50./.

5. plasma glucose > 100 ./.

metabolic syndrome

(), apo B small dense LDL HDL-C

apo A1
LDL-C
Non-HDL-C < 130 ./. apo B < 100 ./.

158

 4 (total cardiovascular risk)

1. 3
1.1

1.2
1.2.1 (abdominal aortic aneurysm),
symptomatic carotid artery disease
1.2.2
1.2.3 10
Framingham risk score 20%
1.3 1
-
-
- HDL-C < 40 ./.
- < 55
< 65
- > 45 > 55
HDL-C > 60 ./. 1
10 Framingham risk score
0-10%

2.
Framingham risk score 10
10-20%

3. 1
3.1

3.2
3.2.1 (abdominal aortic aneurysm)
symptomatic carotid artery disease
3.2.2
3.2.3 10
Framingham risk score 20%

Statin

159

 3.3 2
-
-
- HDL-C < 40 ./.
- < 55
< 65
- > 45 > 55
HDL-C > 60 ./. 1
10 Framingham risk score
20-30%
3.4 (eGFR 60. / / 1.73 2
)

4.
4.1 (acute coronary syndrome)
4.2
10
Framingham risk score 30%

160

LDL-C

++

4,5,6

Non HDL-C

combined hyperlipidemia, ,
metabolic syndrome CKD

HDL-C

Statin

161

 6 LDL-C

162

LDL-C 70 ./.
LDL-C
50%

++

8,9

LDL-C 100 ./.

8,9

LDL-C
130 ./.

8,9,10

LDL-C 160 ./.

+/-

10

 7
(8)

- 2 1-12

- 4-12

- 4-12

- 1 (
)
(ALT; alanine aminotransferase) (CK; creatine
phosphokinase)

- ALT CK

- ALT 4-12

- ALT 1

- ALT 3

-

- ALT 4-6

- ALT 3

- statin ALT 4-6

- ALT

- CK 5
CK

- CK

- CK

- CK



- CK 5

- CK 2

Statin

163

164

- CK
hypothyroidism
- (myopathy) CK
- CK 5
- (
CK )
- CK

 8


statin
9
1
LDL-C
statin

++

4-6

3
1) statin
+
2) statin statin
+

3) cholesterol absorption inhibitor
+/-
statin
( 1)
LDL-C
statin

1) statin statin

2) cholesterol absorption inhibitor

3
3
3

+/-

Statin

165

 1 statin

statin

166

LDL-C

LDL-C

LDL-C

LDL-C

statin

2
1.
statin statin

2. cholesterol
absorption inhibitor
statin

statin

2
1.
statin


statin

2.

cholesterol
absorption inhibitor,
bile acid sequestrant
nicotinic acid

 9 statin Chronic Kidney Disease (CKD)(13-14)

Statins (./)
Atorvastatin
Fluvastatin
Lovastatin
Pravastatin
Rosuvastatin
Simvastatin
Pitavastatin

CKD stages 1-2

CKD stage 3

CKD stages 4-5

Kidney transplant

10-80
20-80
10-80
10-40
5-40
5-40
1-4

10-80
20-80
10-80
10-40
5-20
5-40
1-4

10-80
10-80
10-40
10-20
5-10
5-20
1-2

10-20
10-80
10-40
10-20
5
5-20

Statin

167

 2 statin
1 atorvastatin 40 . (26-29 ;

.. 2555

)

( 31
.

15-19
)
Atorvastatin 40 . (ge6%
52-58
26 29
neric) 2
(26-29 )
Atorvastatin 80 .
6%
49.98
20.98-23.98
Rosuvastatin 20 .
3-10%
55.93
26.93 29.93
30 37.45
Ezetimibe + atorvastatin
15-20%
37.45 + 26 29 =
40 .(generic) ()
63.45 66.45 2
( 2 )
Ezetimibe + simvastatin
1-6%
38.66 2
9 12.66
20 . (generic) ()
( 2 )
Ezetimibe + simvastatin
1-6%
51.96
22.96 25.96
20 . ()
Ezetimibe + simvastatin
10%
39.14 2
10.14 13.14
40 .(generic) ()
( 2 )

168

 2 Incremental Cost-Effectiveness Ratio (ICER) atorvastatin 40 .

()
( 31
% LDL-C

reduction15-19
.
)

ICER*

Atorvastatin 40 . generic

9,360

48%

Atorvastatin 40 . generic
2

18,720

54%

1,560

Atorvastatin 80 .

21,816

54%

2,076

Rosuvastatin 20 .

16793.28

51-58%

22,842

63-68%

13,917.60

49-54%

18,705.6

49-54%

14,090.4

58%

Ezetimibe + atorvastatin
40 . ()
Ezetimibe + simvastatin
20 . ()
Ezetimibe + simvastatin
20 . (combine)
Ezetimibe + simvastatin
40 . ()

743.332477.76
674.1898.8
759.64,557.6
1,557.69,345.6
473.04

* ICER20 = (cost1-cost2)/(effectiveness1- effectiveness2) 1% LDL-C reduction 1

ICER
1 2 .. 2555
statin ICER
ICER
statin

Cyclo-oxygenase 2 Inhibitors

169

 3 statin
1

1. ezetimibe 10 . simvastatin 40 . LDL-C

atorvastatin 80 . ( 1 2 2)

2. ezetimibe 10 . atorvastatin 40 . LDL-C
atorvastatin 80 . ( 1 2 2)

ICER (Incremental Cost-Effectiveness Ratio) ezetimibe
simvastatin 40 . () ezetimibe atorvastatin 40 . (generic)
ICER ( 1 2 2)
( +/-)

2

statin statin statin
cholesterol absorption inhibitor ezetimibe statin
cholesterol absorption inhibitor

3

LDL-C 70 ./.
ezetimibe 10 .
ezetimibe simvastatin
ezetimibe ( +)


pravastatin, fluvastatin, pitavastatin, rosuvastatin
( +)

contraindication drug interaction
( +)


( +)

170

 statin

1. LDL-C
( +)

2. (
+)

3. drug interaction
( +)
statin
statin

Cyclo-oxygenase 2 Inhibitors

171


1. , .
[]. 2554 [ 7 2555] : 1-23. : URL:http://www.surgeons.
or.th/spaw2/uploads/files/CPG%20handbook.pdf
2. . [].
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guidelines/lipidguideline.pdf.
3. European Society of Cardiology. Recommendation for guideline production [online] 2010
[cited 2012 Dec 7]. Available from: URL:http://www.escardio.org/guidelinessurveys/escguidelines/Documents ESC%20Guidelines%20for%20Guidelines%20Update% 202010.pdf.
4. Grundy SM, et al. Diagnosis and management of the metabolic syndrome: an American
Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation
2005;112:e285-90.
5. Cholesterol Treatment Trialists (CTT) Collaboration. Efficacy and safety of more intensive
lowering of LDL cholesterol: a meta-analysis of data from 170000 participants in 26 randomised trials. Lancet 2010;376:167081.
6. Brugts JJ, et al. The benefits of statins in people without established cardiovascular disease
but with cardiovascular risk factors: meta-analysis of randomized controlled trials. BMJ
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7. Mills EJ, et al. Primary prevention of cardiovascular mortality and events with statin treatments: A network meta-analysis involving more than 65,000 patients. J Am Coll Cardiol
2008;52:1769-81.
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Journal 2011;32:1769-1818.
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high blood cholesterol in adults (adult treatment panel III). JAMA 2001;285:2486-97.
10. Sniderman AD, et al. A meta-analysis of low-density lipoprotein cholesterol, non-highdensity lipoprotein cholesterol, and opolipoprotein B as markers of cardiovascular risk.
Circ Cardiovasc Qual Outcomes 2011;4:337-45
11. Tyroler HA. Cholesterol and cardiovascular disease: An overview of lipid research clinics
(LRC) epidemiologic studies as background for the LRC coronary primary prevention trial.
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172

13. National Kidney Foundation. KDOQI clinical practice guideline for diabetes and chronic
kidney disease: 2012 update. Am J Kidney Dis 2012;60:850886.
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Available from:URL:http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=b3c41a2fda77-4465-8af6-038006a7ea58.
15. Jones P, Kafonek S, Laurora I, Hunninghake D.Comparative dose efficacy study of atorvastatin
versus simvastatin, pravastatin, lovastatin, and fluvastatin in patients with hypercholesterolemia (the CURVES study). Am J Cardiol 1998;81:582-7.
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MA, Young LY, Alldredge BK, Corelli RL Guglielmo BJ, Kradjan WA, et al. Applied therapeutics
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P.385-407
20. , . 1 .
. : ; 2552.

Cyclo-oxygenase 2 Inhibitors

173

 1
Statin

Simvastatin

Atorvastatin

Pravastatin

Rosuvastatin

Fluvastatin

Pitavastatin

10-20.

40 ./

simvastatin
80./

simvastatin
80./

12

10-20 .
1

40.
1

5 .
1

20 ./
1

1-2 .

80 ./

40 ./

40 ./

80 ./

4./

cyclosporine

gemfibrozil

itraconazole

ketoconazole

posaconazole

erythromycin

clarithromycin

174

5 ./ 20 .
2
10.

20 ./

rosuvastatin

10
./
20 ./

N/A

1 ./

20 ./ 40 ./


fluconazole

telithromycin

danazole

verapamil

diltiazem

amiodarone,
ranolazine

amlodipine

protease
inhibitors

tipranavir plus
ritonavir

lopinavir plus
tironavir

atanazavir plus
ritonavir

saQuinavir plus
ritonavir

darunavir plus
ritonavir

fosamprenavir,
fosamprenavir
plus ritonavir

Simvastatin

Atorvastatin

Pravastatin

Rosuvastatin

Fluvastatin

10 ./

10 ./

20 ./

20 ./

10 ./

10 ./

20 ./

20 ./

20 ./

420 .
2

Pitavastatin

Cyclo-oxygenase 2 Inhibitors

175


boceprevir

nelfinavir

telaprevir

nefazodone

rifampin

colchicine

fibrates

176

Simvastatin

Atorvastatin

Pravastatin

Rosuvastatin

Fluvastatin

Pitavastatin

40 ./

atorvastatin

myopathy
myopathy
myopathy

rhabdomyolysis rhabdomyolysis rhabdomyolysis

2 ./

myopathy

rhabdomyolysis