Q: I’ve read news reports about Vytorin. Is it still effective to control my cholesterol?

Ask Our Expert about Vytorin for Lowering Cholesterol

• I've read news reports about Vytorin. Is it still effective to control my cholesterol?
• What should I do if I'm still taking Vytorin?

Q: I've read news reports about Vytorin. Is it still effective to control my cholesterol?

A: Controversy surrounding the effectiveness of Vytorin arose when the results of the ENHANCE trial were published earlier this year. The purpose of this trial was to see if combining two cholesterol-lowering drugs, Ezetemibe (Zetia) and Simvastatin (Zocor) in the form of Vytorin was more effective than treatment with Simvastatin (Zocor) alone in reducing cholesterol plaque buildup in the arteries that supply blood to the brain (carotid arteries).

Both Zocor and Vytorin are used to lower bad cholesterol (LDL). Zocor is a statin and decreases production of cholesterol by the liver. Zetia acts by decreasing cholesterol absorption from the intestine. Vytorin is a combination of these two medications.

In the ENHANCE trial individuals treated with Vytorin achieved lower LDL cholesterol levels compared to people treated with Zocor. However there was no significant difference in carotid artery plaque buildup between the two groups. These results naturally raise the question: Is Vytorin helpful, or is Simvastatin (a generic drug) effective enough?

The short answer is, we don't know yet. To appropriately answer this question, however, we need to look at what the study showed and what it did not show.

The study looked at how effective Vytorin and Zocor alone were at reducing plaque buildup in neck arteries, as measured by ultrasound, in people who were genetically prone to high cholesterol. It did not address whether or not Vytorin was better than Zocor in reducing the future risk for having a heart attack, stroke or death. Clinically this is what cardiologists are interested in learning. This question is currently being addressed by an ongoing study, the results of which should be available in the next two years.

You may ask why Vytorin was no more effective in reducing plaque buildup in carotid arteries compared to Zocor. There are many possible explanations, but most center around the fact that the study had significant methodological limitations. Most patients were pre-treated with a statin, thus baseline carotid thickness was actually in the normal range.

So how should the ENHANCE trial results be incorporated into our understanding of heart disease and treatment of cholesterol? First, elevated LDL cholesterol remains a significant risk factor for cardiovascular disease, and its lowering decreases the risk for suffering a heart attack or dying. We also know that in individuals with known heart disease, the lower the LDL, the better. Second, Vytorin and Zocor appear safe. Third, the addition of Zetia to a statin further reduces LDL cholesterol. Ongoing studies are being conducted to determine if this additional lowering in cholesterol further improves survival and reduces future heart attack risk.

The American College of Cardiology (ACC) says patients should not panic, and that further research is needed on the effectiveness of Zetia to improve survival and reduce heart attack risk. In an official statement, the ACC encourages that all patients who require drug treatment to lower LDL cholesterol receive a statin at the maximal tolerated dose to achieve their LDL goal. The addition of Zetia may be appropriate in patients intolerant to a statin or those significantly above goal even though they're on a maximum dose of statins.

Q: What should I do if I'm still taking Vytorin?

A: Talk to your doctor. He or she can review what your LDL cholesterol goal should be and the best way to achieve it. Your doctor can help determine the best medication for you to reach your cholesterol goal; in other words, whether you need a statin alone or the combination of a statin with another medicine such as Zetia. All medications have different benefits and risks. Remember, diet, exercise, and smoking cessation also can help prevent heart problems.

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