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Definition of Oily Fish NHFA Position Statement

Definition of Oily Fish NHFA Position Statement. Lean < 1% Fat (body weight) e.g. Cod, trout Intermediate 1 - 10% Fat e.g. Trout, sea bass, bream Oily > 10% Fat e.g. Atlantic salmon, herring, swordfish. www.heartfoundation.org.au. www.heartfoundation.org.au.

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Definition of Oily Fish NHFA Position Statement

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  1. Definition of Oily FishNHFA Position Statement • Lean < 1% Fat (body weight) e.g. Cod, trout • Intermediate 1 - 10% Fat e.g. Trout, sea bass, bream • Oily > 10% Fat e.g. Atlantic salmon, herring, swordfish

  2. www.heartfoundation.org.au

  3. www.heartfoundation.org.au

  4. Marine n-3 PUFA Content in fish with recommended intake

  5. USA Comparison of mercury and marine n-3 PUFA content in fish

  6. NHFA Update 2010New Clinical Outcome Trials

  7. OMEGA-3TRIAL Chief author/investigator Dr Jochen Serges “The study was underpowered to show an effect because of the low rate of sudden cardiac death” Serges explained. “It would be incorrect to say that omega-3 fatty acids are not effective” Ref: ACC Scientific Sessions March 2009 www.theheart.org/article April 3, 2009

  8. GISSI-HF TRIAL(Gruppo Italiano per Lo Studio della Sopravvivenza nell’Infarcto Miocardio Prevenenzione Trial) • 6,975 patients from 357 Italian centres with CHF NHA Class II-IV irrespective of EF • 2X2 Factorial design • Omega-3 (EPA & DHA 850-882 mg) vs placebo • Rousvastatin 10mg vs placebo) • Follow-up median 3.9 years Ref: GISSI-HF Investigators. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (The GISSI-HF Trial): a randomised, double blind, placebo controlled trial. Lancet 2008 372;9645:1223-1230

  9. GISSI-HF TRIAL

  10. GISSI-HF TRIAL PRIMARY END-POINT OVER 3.9 YEARS Omega-3 Placebo Hazard Ratio End-Point n % n % Death 955 27% 1014 29% 0.91 P=0.04 (CI 0.83 – 0.99) Death or CV 1981 57% 2053 59% 0.92 P=0.009 admission (0.84 – 0.99) 56 Patients NNT median 3.9 years to avoid death 44 Patients NNT to prevent death or CV admission GI side effects 96 (3%) in Omega 3 vs 92 (3%) in placebo Discontinued therapy 1004 (28.7% in Omega 3 vs 1029 (29.6%) GISSI-HF Investigators Lancet Online Aug 31,2008:1-8

  11. NHFA Update 2010 • Awareness of poor implementation of Position Statement • Different kinetics of fish oil triglycerides and ethyl ester derivatives (may modify recommendations similar to NICE.)

  12. Physiology of Triglycerides and Omega-3 ethyl esters • The ESTER bond influences absorption kinetics of EPA and DHA in duodenum. • All forms are not fully absorbed • Triglycerides rapidly digested by (Pancreatic lipase), less active if they contain EPA/DHA (due to double bond position) PUFA by <Carboxyl ester hydrolase> • Compared to triglycerides ethyl esters of EPA/DHA are more slowly absorbed from duodenum into lymph and via thoracic duct into the bloodstream. Ikeda I et al. Life Sciences 1993;52:1371-9 Lawson L et al. Biochem and Biophysical Res Comm 1988;152:328-335

  13. Clinical implications of ethyl ester EPA/DHA therapy VS Fish Oil Triglycerides • Less saturated fatty acids • Less LDL-raising effect • Less contaminants (e.g. mercury) • Greater compliance as one-third as many capsules • Greater protection at vulnerable SCD time in AM (due to kinetics) • Use of proven form of EPA/DHA in clinical outcome trials

  14. NICE Recommendations for Secondary Prevention “Consume at least 7 g of omega-3 fatty acids per week from 2-4 portions of oily fish per week. If within 3 months of a myocardial infarction and they are not achieving this, consider providing at least 1 g daily of omega-3 acid ethyl esters treatment licensed for secondary prevention after myocardial infarction for up to 4 years. Initiation of omega-3 acid ethyl esters supplement treatment is not routinely recommended in patients that have had a myocardial infarction more than 3 months earlier (no evidence of benefit)” JS Skinner et al. HEART 2007;93(7) 862-64

  15. NHFA Update 2010 Mechanisms: EPA/DHA • lowers Non-LDL cholesterol • restores anti-platelet effect of aspirin and Clopidogrel in resistant patients • with aspirin, formation of anti-inflammatory resolvins and protectins • may improve depression

  16. Aspirin Resistance in CHD patients improved by omega-3 or dose increase 30 pts (6.2%) were ASA-R Randomized to 75-162mg ASA & Omega 3 or ASA 325mg / day Omega 3 : EPA 360 & DHA 240 x 4 / day (OmegaMax 3) Exclusion: - PCI within 1 month - Concomitant treatment with omega-3, NSAID or warfarin Lev EI, Solodky A, et al. JACC 2010 Vol 55 (2):114-21

  17. Aspirin resistance in CHD patients improved by omega-3 or dose increase 30 pts with ASA resistance (ASA-R) had repeat platelet testing at 30 days and one year 20 control – no change in platelet function tests Aspirin resistance was largely abolished with increased ASA dose or addition of Omega-3 Lev EI, et al. Treatment of ASA-R. J Am Cardiol 2010;55:114-21

  18. NHFA Update 2010 COMPLIANCE: • Compliance is a critical issue for primary and secondary prevention. • Minimizing number of pills is a factor. • Ideal source of EPA/DHA is most concentrated and devoid of potential contaminants.

  19. NHFA Update 2010 SUSTAINABILITY: • Fish stocks long term are fragile. • Awareness that fish do not synthesize EPA/DHA. • Phytoplankton (algae, cyanobacteria) make EPA/DHA found in fish. • Algal bioreactors (farms) are a direct source for sustainable EP/DHA for health and energy to power industry.

  20. Access Economics Report on cost Effectiveness of Complementary Medicines • Cost effective therapy for CHD • Access Economics 2010 Report commissioned by National Institute of Complementary Medicine (NICM) released in September 2010

  21. Access Economics report on Cost Effectiveness of Complementary Medicines • “Fish oils were found to be highly cost effective – consistent with other international cost effectiveness studies. The incremental cost per person was $128 per annum and the incremental effectiveness 0.06 DALYs. The cost per DALY avoided was $2.041. Sensitivity analysis was conducted around treatment effect variables (MI, stoke, revascularisation, CHD mortality and other mortality). The results remained highly cost effective under all of the sensitivity scenarios, evaluated against all the cost effectiveness thresholds. Where dietary changes cannot be made (or sustained) there is a clear role for the use of dietary supplements to provide the necessary dietary intake of EPA and DHA”.

  22. Number Needed to Treat to Prevent CHD Event over 5 years

  23. Summary of NHFA Position on fish, fish oils and omega-3 fatty acids 2010 • Position Statement 2008 confirmed. • New data refines certainty about recommendations (GISSI-HF). • Aspirin/Clopidogrel resistance is improved (OMEGA-PCI). • Need to publicize recommendations. • TGA approval and PBS listing ought to make EPA/DHA more affordable, and aid compliance of patients and doctors to “get with the guidelines”. • May specifically recommend like NICE: omega-3-acid ethyl esters rather than any source of EPA/DHA (triglycerides or phospholipids).

  24. Contact

  25. “Nothing will benefit human health and increase the chances for survival of life on Earth as much as the evolution of a vegetarian diet ” & the addition of fatty fish weekly for healthy adults and ethyl ester EPA/DHA 1000mg per day for those with CHD (The Quotable Colquhoun!)The Quotable EinsteinNew Jersey 1996

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