NCEP Goal Attainment: SIMCOR (niacin-extended-release/simvastatin tablets)

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SIMCOR (niacin extended-release/simvastatin) is indicated as an adjunct to diet to reduce total‑C, LDL-C, Apo B, non-HDL-C, or TG, or to increase
HDL-C in patients with primary hypercholesterolemia and mixed dyslipidemia (Fredrickson Types IIa and IIb) when treatment with simvastatin monotherapy or niacin extended-release monotherapy is considered inadequate.

Limitations of use: No incremental benefit of SIMCOR on cardiovascular morbidity and mortality over and above that demonstrated for simvastatin monotherapy and niacin monotherapy has been established.

NCEP guidelines support combination therapy to reach therapeutic goals/targets¹

NCEP classification of lipid cholesterol¹

GOALS	For patients with CHD or CHD risk equivalents	For patients with 2+ risk factors	For patients with 0-1 risk factors
LDL-C	<100 mg/dL	<130 mg/dL	<160 mg/dL
Non–HDL-C*	<130 mg/dL	<160 mg/dL	<190 mg/dL
	* Non–HDL-C goal is 30 mg/dL higher than the LDL-C goal

HDL-C	LOW^†	HIGH
HDL-C	<40 mg/dL	>60 mg/dL
	† According to the AHA, <40 mg/dL is low for men; <50 mg/dL is low for women²

<150 mg/dL defined as normal

Please click here for Important Safety Information you should know about SIMCOR.

SIMCOR helped a majority of patients attain optimal lipid levels

SEACOAST II Post hoc Analysis^{*3, 4}

Percentage of patients that attained optimal lipid levels at last visit including those already at goals at baseline

SIMCOR 2000/40 mg (n= 98): LDL-C, 67%; HDL-C, 95%; TG, 79%; non-HDL-C, 72%
SIMCOR 1000/40 mg (n=111): LDL-C, 70%; HDL-C, 89%; TG, 66%; non-HDL-C, 70 %
Simvastatin 80 mg (n=113): LDL-C, 82%; HDL-C, 75%; TG, 54%; non-HDL-C, 77%

*LDL-C targets were similar to NCEP goals/targets. LDL-C targets were CHD risk equivalent; < 100 mg/dL; ≥ 2 risk factors: < 130 mg/dL; ≤ 1 risk factor < 160 mg/dL, HDL-C target: ≥ 40 mg/dL, TG target: < 150 mg/dL. Non-HDL-C targets were an additional 30 mg/dL to each LDL-C target

Percentage of mITT patients receiving up to SIMCOR 2000/40 mg that reached optimal lipid levels at 24 weeks (N=463)^{3, 5, ‡}

Results for patients on treatment at 24 weeks (n=268)

>80% of patients receiving up to SIMCOR 2000/40 mg attained optimal lipid levels^{3, 5, ‡, §}

≥80% of SIMCOR patients attained optimal lipid levels

View Larger Graph

‡ Includes patients who were already at optimal lipid levels at baseline. Percentage of patients at optimal lipid levels at baseline: mITT—
LDL-C=47%; HDL-C=30%; TG=50%; non–HDL-C=45%. On-treatment patients—LDL-C=50%; HDL-C=69%; TG=50%; non–HDL-C=49%

§ OCEANS study targets were similar to NCEP goals/targets. LDL-C targets were CHD risk equivalent; <100 mg/dL: ≥2 risk factors: < 130 mg/dL: ≤ 1 risk factor: < 160 mg/dL. HDL-C target ≥40 mg/dL . TG target < 150 mg/dL. Non-HDL-C targets were an additional 30 mg/dL to each
LDL-C target. See SIMCOR 2000/40mg (OCEANS all patients) Page for OCEANS study design

Safety Considerations for SIMCOR

SIMCOR is contraindicated in patients with active liver disease or unexplained persistent elevations of serum transaminases, active peptic ulcer disease, arterial bleeding; in women who are pregnant or may become pregnant; in nursing mothers; and in patients with hypersensitivity to any product ingredient.

Myopathy and/or rhabdomyolysis have been reported when simvastatin is used in combination with lipid-altering doses (≥1 g/day) of niacin. Patients on SIMCOR should be monitored for muscle pain, tenderness or weakness, particularly during the initial month of treatment or during upward dose titration. Periodic CK determinations may be considered in such situations, but there is no assurance that such monitoring will prevent myopathy. SIMCOR therapy should be discontinued if CK levels above 10x ULN occur or if myopathy is diagnosed or suspected.

Efficacy
Additional Lipid Data

SIMCOR 2000/40 mg (OCEANS-all patients)
SIMCOR 2000/40 mg (OCEANS-treatment-naive)
NCEP Goal Attainment

References:

National Heart, Lung, and Blood Institute. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). National Institutes of Health; 2002. NIH publication 02-5215.
American Heart Association. Cholesterol levels: AHA recommendation. Available at: www.americanheart.org/presenter.jhtml?identifier=4500. Accessed August 25, 2009.
Data on file, Abbott Laboratories.
Ballantyne CM, Davidson MH, McKenney JM, et al. Comparison of the efficacy and safety of a combination tablet of niacin extended-release and simvastatin with simvastatin 80 mg monotherapy: the SEACOAST II(high-dose) study. J Clin Lipid. 2008;2:78-90.
Karas, RH, Kashyap, ML, et al. Long-Term Safety and Efficacy of a Combination of Niacin Extended-Release and Simvastatin in Patients with Dyslipidemia: The OCEANS Study. Am J Cardio Drugs. 2008; 8(2):69-81.

Indications and Important Safety Information You Should Know About SIMCOR

Indications

Lipid-altering agents should be used in addition to a diet restricted in saturated fat and cholesterol when response to diet and other nonpharmacological measures alone has been inadequate.
SIMCOR® (simvastatin/niacin extended-release) is indicated as an adjunct to diet to reduce total‑C, LDL-C, Apo B, non-HDL-C, or TG, or to increase HDL-C in patients with primary hypercholesterolemia and mixed dyslipidemia (Fredrickson Types IIa and IIb) when treatment with simvastatin monotherapy or niacin extended-release monotherapy is considered inadequate.
SIMCOR is indicated to reduce TG in patients with hypertriglyceridemia (Fredrickson Type IV hyperlipidemia) when treatment with simvastatin monotherapy or niacin extended-release monotherapy is considered inadequate.
Limitations of use: No incremental benefit of SIMCOR on cardiovascular morbidity and mortality over and above that demonstrated for simvastatin monotherapy and niacin monotherapy has been established.

Important Safety Information

SIMCOR is contraindicated in patients with active liver disease or unexplained persistent elevations of serum transaminases, active peptic ulcer disease, arterial bleeding; in women who are pregnant or may become pregnant; in nursing mothers; and in patients with hypersensitivity to any product ingredient.
SIMCOR contains simvastatin, which occasionally causes myopathy manifested as muscle pain, tenderness, or weakness with CK levels above 10x ULN. Myopathy sometimes takes the form of rhabdomyolysis with or without acute renal failure secondary to myoglobinuria, and rare fatalities have occurred. The risk of myopathy/rhabdomyolysis is dose-related and is increased by high plasma concentrations of a statin.
Caution should be exercised when SIMCOR is administered to patients with renal disease.
The use of SIMCOR concomitantly with potent CYP3A4 inhibitors: itraconazole, ketoconazole and other antifungal azoles; erythromycin, clarithromycin and telithromycin; HIV protease inhibitors; nefazodone; and grapefruit juice in large quantities (>1 quart daily) should be avoided because of the increased risk of myopathy/rhabdomyolysis. Concomitant use of SIMCOR with cyclosporine, danazol, gemfibrozil, other fibrates, amiodarone, and verapamil should also be avoided because of increased risk of myopathy/rhabdomyolysis.
Myopathy and/or rhabdomyolysis have been reported when simvastatin is used in combination with lipid-altering doses (≥1 g/day) of niacin. Patients on SIMCOR should be monitored for muscle pain, tenderness or weakness, particularly during the initial month of treatment or during upward dose titration. Periodic CK determinations may be considered in such situations, but there is no assurance that such monitoring will prevent myopathy. SIMCOR therapy should be discontinued if CK levels above 10x ULN occur or if myopathy is diagnosed or suspected.
SIMCOR should not be substituted for equivalent doses of immediate-release niacin. Severe hepatic toxicity, including fulminant hepatic necrosis, has occurred in patients substituting sustained-release niacin for immediate-release niacin at equivalent doses. If switching from immediate-release niacin to SIMCOR, initiate with the lowest SIMCOR dose (500/20 mg) and titrate to the desired therapeutic response. Doses greater than 2000/40 mg are not recommended.
SIMCOR should be used with caution in patients who consume substantial quantities of alcohol and/or who have a past history of liver disease.

Liver function tests should be performed on all patients before treatment begins and every 12 weeks for the first 6 months, and periodically thereafter (eg, at approximately 6-month intervals). Should an increase in transaminase levels of more than 3x ULN persist, or if transaminase elevations are associated with symptoms of nausea, fever, and/or malaise, withdrawal of SIMCOR therapy is recommended.
Niacin treatment can increase fasting blood glucose. Glucose levels should be closely monitored in diabetic or potentially diabetic patients particularly during the first few months of use. Adjustment of diet and/or hypoglycemic therapy or discontinuation of SIMCOR may be necessary.
Niacin can reduce platelet count and phosphorus levels and increase uric acid levels.
In patients taking coumarin anticoagulants, monitor prothrombin time and INR before initiating SIMCOR and frequently after initiation or alteration of SIMCOR therapy until stable.
The most common adverse event with SIMCOR is flushing (warmth, redness, itching and/or tingling) which occurred in 59% of patients and resulted in study discontinuation for 6% of patients. Flushing may vary in severity and is more likely to occur with initiation of therapy or during dose increases. Spontaneous reports with niacin extended-release and clinical studies of SIMCOR suggest that flushing may be accompanied by symptoms of dizziness, syncope, tachycardia, palpitations, shortness of breath, sweating, chills and/or edema.
Other common adverse events occurring in ≥3% of patients treated with SIMCOR included headache, pruritus, nausea, back pain, and diarrhea.

Reference:

SIMCOR [package insert]. North Chicago, IL: Abbott Laboratories.

NCEP guidelines support combination therapy to reach therapeutic goals/targets1

NCEP classification of lipid cholesterol1