The use of lipid-modifying therapy in South Asian patients with established
coronary heart disease results in reductions in LDL cholesterol and increases in
HDL cholesterol similar to those in white patients, according to the results of
a new study [1]. The findings suggest that South Asian patients be treated with
atorvastatin and simvastatin, the two most commonly prescribed statins in this
retrospective analysis, at doses that would be prescribed to white patients, say
researchers.

"Applicability is limited in that these are patients with coronary disease, as
opposed to a primary-prevention¡Vtype population, and we really only had the
power to evaluate simvastatin and atorvastatin," said lead investigator Dr Milan
Gupta (McMaster University, Hamilton, ON). "But I think it's a reasonable
conclusion that in South Asians with coronary disease in whom you are
prescribing simvastatin or atorvastatin, if you're concerned you might not get
the same lipid effect as in a white population, that concern is unfounded."

The results of the study are published online April 27, 2009 in the Journal of
Clinical Pharmacology.

Speaking with heartwire , Gupta explained that there exists a generalized
notion, derived from studies of East Asian, primarily Japanese, populations,
that Asian patients require lower doses of statins. This generalization has
extended to South Asians from the Indian subcontinent, such as those from India,
Pakistan, Sri Lanka, Nepal, and Bangladesh. The Canadian Cardiovascular Society
guidelines, for example, recommend the use of lower statin doses for all Asian
patients. Also, the Food and Drug Administration recommends all Asian patients
start with rosuvastatin 5 mg.

In an analysis of the ongoing Prospective Assessment of Cardiovascular Risk and
Treatment of Canadians of Varying Ethnicity (PRACTICE) registry, the researchers
wanted to compare the lipid-modifying effects of statin therapy in South Asian
and white patients with documented coronary heart disease. To assess the effects
of statins, the group contacted the primary-care physician and obtained baseline
LDL- and HDL-cholesterol levels prior to starting statin therapy. The selection
and dosing of statin therapy was at the discretion of their doctor, but the goal
was to treat patients to secondary-prevention lipid targets. Most patients were
treated with atorvastatin and simvastatin 20 mg, and all were treated with the
drugs for a minimum of six weeks.

Both statins resulted in similar decreases in LDL cholesterol: 35% and 43% with
simvastatin and atorvastatin, respectively, in South Asians, and 37% and 41% in
white patients. There were similar increases in HDL-cholesterol levels with both
statins in both patient populations. Regression analyses showed that the
expected decrease in LDL cholesterol for atorvastatin 10 mg and 20 mg was
similar with both groups of patients.

"There is a similar degree of LDL lowering, dose for dose, and there is a
similar effect on HDL cholesterol, in South Asians and Caucasians," said Gupta.
"We can't make conclusions for the other statins, because their usage was quite
infrequent in this patient population. However, in this type of population,
there doesn't appear to be any need to alter the dose of atorvastatin or
simvastatin, at least with respect to lipid efficacy."

Speaking with heartwire , Dr James de Lemos (University of Texas Southwestern,
Dallas) said that most clinicians are aware the South Asian patients have a
higher risk-factor profile than other patients, but that he is not surprised by
the findings, given the genetic dissimilarities between East Asian and South
Asian patients. He added that he sees a large number of South Asian patients in
his clinic, but he does not prescribe lower statin doses for them. Dr Roger
Blumenthal (Johns Hopkins University Medical Center, Baltimore, MD) agreed with
de Lemos, noting that even starting Japanese patients on lower doses remains
controversial in clinical practice.