Results from a new TNS survey of primary and secondary care physicians (general practitioners and cardiologists) across Europe, released today, shows that nearly three quarters (72 percent) of physicians surveyed feel that many hypercholesterolemia patients with risk factors such as coronary heart disease (CHD) and/or diabetes may be insufficiently treated by statin monotherapy in broad clinical practice. [1] In fact, nearly half (48 percent) of physicians surveyed knew that doubling the dose of any statin only provides an incremental six percent increase in LDL-C lowering. Additionally, the survey data revealed that 64 percent of physicians surveyed agreed or strongly agreed that they are reluctant to prescribe high dose statins in patients with risk factors because of concerns around safety and side effects. Lastly, limitations with statin therapy was also cited by the majority of physicians questioned (69 percent) as the reason why guidelines are not adequately followed. These limitations include:

* Statin monotherapy is not effective for getting at risk patients to goal * Risks associated with high dose statins * Time/multiple visits required for titrating a statin

Commenting on the survey results, Professor Jose Luis Zamorano, Associate Professor of Medicine and Director, Non-Invasive Cardiovascular Imaging Laboratory, Hospital Clinico, San Carlos, Spain said: "According to this survey, three-quarters of physicians recognize that statin monotherapy may be insufficient for achieving LDL-C goals in high risk patients. However, it's crucial that patients reach their LDL-C goals. In addition, it's vitally important that these high risk patients are assessed for total CVD risk, and one of the cornerstones of CVD risk management is lipid lowering. Different trials are suggesting - and guidelines are demanding - lower LDL-C levels to reduce total CVD risk. Physicians need to consider using newer treatment approaches, to help their high risk patients achieve LDL-C goals."

The majority of physicians surveyed (86 percent) agreed that treating the two sources of cholesterol -- the absorption of cholesterol in the intestine and production in the liver -- is likely to achieve greater reductions in LDL-C than treating just liver production alone. Statin monotherapy only treats cholesterol production in the liver.

Professor Alberico Catapano, Professor of Pharmacology, University of Milan, said: "Statin therapy can be very effective, but if physicians recognize that high doses are undesirable, we need to look at treatment alternatives and combination therapy. Newer therapies like ezetimibe co-administered with a statin differ from statins alone because they treat the two sources of cholesterol; they inhibit both absorption of cholesterol in the intestines and cholesterol production in the liver, to achieve greater reductions in LDL-C levels. Adding a cholesterol absorption inhibitor to a statin provides a greater reduction in LDL-C than doubling the dose of a statin."

Goal attainment
The majority (seven out of ten) of the primary and secondary care physicians surveyed believed that only half or less of their at-risk patients (those with diabetes or CHD) with hypercholesterolemia have reached their target LDL-C goal. In addition, significantly more primary care than secondary care physicians felt that guidelines are not adequately followed because getting patients to within 80 or 90 per cent of LDL-C goal is close enough (17 percent vs. 11 percent respectively; p=0.05).

Confusion over treatment guidelines
In total, 77 percent of physicians surveyed believed that guidelines on the management of hypercholesterolemia are not sufficiently followed. When asked which guidelines, if any, respondents were aware of, for ensuring optimal CV outcomes for patients with CHD and/or diabetes with hypercholesterolemia, significantly more secondary care physicians (cardiologists) were able to state specific treatment guidelines (such as NCEP ATP III, ESC guidelines, AHA guidelines). In parallel however, significantly more primary care physicians (general practitioners) in the survey were unable to cite any guidelines compared to secondary care physicians when asked the above question (39 percent vs.16 percent respectively; p=0.05)

Treating two sources of cholesterol
Cholesterol in the body originates from two main sources: absorption in the intestine of both biliary and dietary cholesterol, and production in the liver and peripheral tissues [2],[3]. Approximately two-thirds of intestinal cholesterol comes from biliary sources; only one third comes from dietary sources [4]. Approximately 50 percent of cholesterol in the intestine is absorbed and re-circulated in the blood; the remainder is excreted [5], [6]
Cholesterol-lowering agents (statins) reduce cholesterol levels through the partial inhibition of one pathway; that is, by inhibiting the production (synthesis) of cholesterol in the liver. INEGY™ (ezetimibe/simvastatin) contains the statin simvastatin, plus the active ingredient of EZETROL™ (ezetimibe), the first and only cholesterol absorption inhibitor which works by inhibiting intestinal absorption of cholesterol. INEGY is the first single product to powerfully target two sources of cholesterol through dual inhibition of cholesterol production and absorption, thus providing greater LDL-C reduction and allowing more hypercholesterolemia patients to reach ESC target of ≤2.5 mmol/l and NCEP ATP III target of ≤70 mg/dl.


About the TNS Survey
This research survey was conducted by leading market research agency TNS among general practitioners and cardiologists in Europe. A total of 879 interviews were conducted, with 100/101 general practitioners and 75/76 cardiologists being questioned in each of France, Germany, Italy, Spain and the UK respectively. TNS conducted this survey to determine the level of understanding around the management of cholesterol levels from the perspective of primary and secondary care physicians. The research was conducted via the internet, with interviews lasting approximately six minutes. The survey contained nine closed-ended and one open-ended question. In addition, five classification questions and three demographics questions were asked. [1]

About Merck
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About Schering-Plough
Schering-Plough is a global science-based health care company with leading prescription, consumer and animal health products. Through internal research and collaborations with partners, Schering-Plough discovers, develops, manufactures and markets advanced drug therapies to meet important medical needs. Schering-Plough's vision is to earn the trust of the physicians, patients and customers served by its more than 32,000 people around the world. The company is based in Kenilworth, N.J., and its Web site is

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1. Survey of European Primary and Secondary Care Clinicians. Cardiovascular Survey: Conducted in July 2006 by TNS. Results on file

2. Shepherd J. The role of the exogenous pathway in hypercholesterolemia. Eur Heart J Suppl 2001;3(suppl E):E2-E5

3. Van Heek M, Farley C, Compton DS et al. Comparison of the activity and disposition of the novel cholesterol absorption inhibitor, SCH58235, and its glucuronide, SCH60663. Br J Pharmacol 2000;129:1748-1754

4. Wilson MD, Rudel LL. Review of cholesterol absorption with emphasis on dietary and biliary cholesterol. J Lipid Res 1994; 35:943-955

5. Clearfield MB. A novel therapeutic approach to dyslipidemia. J Am Osteopath Assoc 2003;103(suppl 1):S16-S20

6. Bays H. Ezetimibe. Expert Opin Investig Drugs. 2002;11(11):15 87-1604

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