Dr. Josh

3 Comments

    • ON: Thu Apr 3rd 20:18 PM
      Commented on:
      Merck, Schering-Plough: Confessions of a Vytorin Patient
      I beleive that higher doses of more potent statin are better than lower doses of less potent statin at preventing cardiac events. This has been shown repeatedly. Whether LDL, TG, APO-B or CRP numbers are important or just epiphenoma, we dont really know at this point. Certainly there are compound which treat these numbers and show no benefit. The most obvious example is torceptrapib. (I suspect zetia will be put in the same category when we know for sure in 2012.)
      Placebo actual does lower all of the things you mentioned in various studies- but that really isn't the point.
      You seem to be quite confused in your reference to Radiance. This was a trial of torceptrapib with lipitor as the baseline in both arms. I don't see what this says about lipitors effectiveness. That would be like trying to say that zocor was ineffective from Enhance.
      @ Wavenet- There is no proof that Zetia is either good for you or bad for you. All we know is that it lowers LDL( a surrogate) and seems to cause a trend to more IMT thinkening in familial hypercholesterolemic patient population than placebo- and that we know it is rather expensive. So I would turn the question on you and ask- Do you have any scientifically acceptable proof that this compound decreases morbidity? Given the lack of proof, I would again suggest you consider Crestor or Lipitor plus niaspan. ( all of which do have this proof.)
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    • ON: Thu Apr 3rd 14:17 PM
      Commented on:
      Merck, Schering-Plough: Confessions of a Vytorin Patient
      If you look at the trial that Merck/SGP did comparing Crestor to Vytorin, you will notice that there were actually more side effects in the vytorin group.
      In patients who can't reach goal on a statin, or cant tolerate a statin, I would add Niaspan, a fibrate, a resin binding agent, and dietary changes and if these all failed I would consider under Zetia- realizing that I am probably just treating my own need to longer lipids and that this intervention is probably not helping the patient.
      If I were WAVENET's doctor, I would switch him to crestor, which would acheive the same LDL reduction, same level of side effects, same cost, but with actual positive trials for both surrogate endpoints and mordibity.
      I would also refer you to an article two years ago- in JACC I beleive- which compared 10 of simva to 10 of zetia. Both acheived the same LDL reduction, but Zetia failed to have positive changes in flow mediated vasoreactivity- a measure of vascular health.
      I can't see any reason to opt for vytorin as a first, second, or third line drug. Fourth line is debatable.
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    • ON: Thu Apr 3rd 13:37 PM
      Commented on:
      Merck, Schering-Plough: Confessions of a Vytorin Patient
      It is always amazing to me how funny some people are. Between the guy who persist on trying to lower his "LDH" and the author who is too blinded by his long position in SGP to take his health into consideration. People seem to disregard CIMT as a surrogate, and focus on LDL which is also of course a surrogate- just a weaker one. There are multiple examples of drugs which lower LDL- or LDH if you prefer- and increase your risk of MI. These include oral contraceptive and torceptrapib.
      A few factual points:
      1- The author compares the cost of vytorin to the cost of generic zocor(simva) plus zetia. The more appropriate comparision would be to generic simva- which would of course be much cheaper. Since this trial suggests that zetia is in fact a glorified placebo.
      2- Not all of the patients in this trial had been on statins. 19% were statin naive. Subset analysis didn't show any difference in these patients. Subset analysis also didn't show any different results in those patients with thicker IMTs. It was these subsets analyses which really cripple the whole argument that MRK/SGP and their stockholders who are posting above are trying to make.
      3- This trial didn't prove safety. It was not an endpoint trial. There were not marked more adverse outcomes in the vytorin arm- That is a very different thing. The drug may well be dangerous and we will have to wait for the large multi-center trial to know that.
      4- In response to the original post- Crestor has unambiguously descreased plaque in arteries- both in the carotids and the coronaries, by CIMT, IVUS, and QCA. Lipitor has been also shown to decrease plaque progression compared to placebo- even in population much like the one studied in ENHANCE. See the ASAP trial
      The better question is which cholesterol drugs have been proved unambiguously to prevent heart attacks. The answer to that question is Simvastatin, Pravachol, Lipitor, Crestor, Mevacor, Gemfibrozil, Niaspan. Really everything except Zetia, vytorin and tricor. It is that question that guides my choice of therapy. I would think that from a patient perspective in might be more important too.
      Disclosure: I am a cardiologist who shorted MRK and SGP on Friday and bought AZN on Monday. (Which I guess means I won) Currently though, no position either long or short in MRK or SGP.
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