DO ALL STATINS NEED TO BE TAKEN AT NIGHT?
Cholesterol is synthesized in the liver while we sleep. Statins work by inhibiting HMG CoA reductase, an enzyme required for the hepatic production of cholesterol. It makes physiologic sense to give statins at bedtime because drug concentrations would then be highest during the time of cholesterol synthesis. In theory, this should maximize the effect of the medication. Indeed this may be true for some statins, particularly those with shorter half-lives.
Simvastatin (Zocor), fluvastatin (Lescol), and lovastatin (Mevacor) are the shortest-acting HMG CoA reductase inhibitors, and they should be given in the evening (lovastatin should be taken with food). Studies with simvastatin have shown cholesterol levels are improved when the drug was administered at night compared to in the morning.1 However, this finding has not been observed with all statins. The manufacturers of atorvastatin (Lipitor), pravastatin (Pravachol), rosuvastatin (Crestor), and pitavastatin (Livalo) state that
the drug may be taken anytime during the day.
Remember that the most important factor with drug therapy is compliance. It is well known that once-daily dosing regimens increase compliance, and many patients prefer to take all of their medications together at the same time. Although some statins may lower cholesterol more effectively if taken in the evening, it is unknown if this translates into better outcomes (fewer heart attacks, etc). If a patient cannot remember to take a statin at night, recommend taking it in the morning with any remaining medications.
WHAT IS THE DIFFERENCE BETWEEN LOVAZA AND OTC FISH OIL SUPPLEMENTS?
Fish oils are a good source of omega-3 fatty acids and are a popular dietary supplement to improve cardiovascular health. The two omega-3 fatty acids found in fish oil that are thought to be beneficial are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The biggest difference between OTC fish oil supplements and prescription Lovaza is the amount of EPA and DHA in each capsule.
Lovaza (omega-3-acid ethyl esters) is generally considered to be more concentrated than OTC fish oil supplements. It is available in 1-gram capsules that contain approximately 375 mg DHA and 465 mg EPA (total of 840 mg omega-3). In contrast, OTC fish oil supplements contain varying amounts of EPA and DHA. Although some OTC products are concentrated, warn patients not to be misled by products that state "double" or "triple strength" because this information is not helpful. Patients should look for the exact amount of EPA and DHA in each capsule and should avoid products that do not state this information.
One argument against OTC fish oil supplements is that they are not regulated and therefore the quality and content of each product may vary. In addition, fish oils may contain toxins such as mercury, heavy metals, polychlorinated biphenyls (PCBs), or dioxins.2 Advise patients to choose supplements that have the United States Pharmacopeia seal "USP Verified" (Figure 1) because these products are tested for purity, quality, and batch consistency. Additionally, USP Verified products are tested for the aforementioned contaminants and have levels that are within safe limits.2
The question still remains: who should use fish oil and in what doses? The American Heart Association (AHA) recommends that everyone eat a variety of oily fish at least twice a week. This is approximately equivalent to 500 mg per day of combined EPA and DHA. One gram of omega-3 fatty acids is recommended for patients with coronary heart disease (again, preferably from oily fish), and up to 4 grams daily may be used in patients with hypertriglyceridemia.
Lovaza is approved only for the treatment of elevated triglycerides at a dose of 4 grams per day. If OTC fish oil supplements are used, pay attention to total EPA and DHA. Tell patients that 8 to 16 capsules may be required, depending on the product purchased. Keep in mind that current guidelines consider fish oil an alternative to fibrates or nicotinic acid for the treatment of hypertriglyceridemia. JAAPA
Larissa DeDea, PharmD, BCPS, PA-C, is a clinical pharmacist with Northern Arizona Healthcare, Flagstaff, Arizona. In addition to being board certified in pharmacotherapy, she is a graduate of the Yale University PA program.
REFERENCES
1. Wallace A, Chinn D, Rubin G. Taking simvastatin in the morning compared with in the evening: randomised controlled trial. BMJ. 2003;327(7418):788.
2. Omega-3 fatty acids: an update. Updated November 2010. Pharmacist's Letter/Prescriber's Letter 2007;23(8):230807.