[Statin-associated muscle symptoms: epidemiology, risk factors, mechanisms and treatment]

Statins are widely prescribed and the risk of adverse drug reactions of lipid-lowering therapy is actively discussed, including muscle symptoms. This review synthesizes the knowledge about the clinical aspects of statin-associated muscle symptoms, which is important for the practitioner. Potential mechanisms of their development, risk factors, clinical manifestations, treatment and prevention are described. Timely detection the side effects of statins makes it possible to diagnose and eliminate, which is crucial for conducting lipid-lowering therapy for patients with atherosclerotic cardiovascular diseases. Management of statin-associated muscle symptoms requires altering (reduced dosages, use of another statin or alternative lipid-lowering drugs) or discontinuing the statin treatment.

It is not just the drugs that matter: the nocebo effect

The role of psychological mechanisms in the treatment process cannot be underestimated, the well-known placebo effect unquestionably being a factor in treatment. However, there is also a dark side to the impact of mental processes on health/illness as exemplified by the nocebo effect. This phenomenon includes the emergence or exacerbation of negative symptoms associated with the therapy, but arising as a result of the patient's expectations, rather than being an actual complication of treatment. The exact biological mechanisms of this process are not known, but cholecystokinergic and dopaminergic systems, changes in the HPA axis, and the endogenous secretion of opioids are thought to be involved. The nocebo effect can affect a significant proportion of people undergoing treatment, including cancer patients, leading in some cases to the cessation of potentially effective therapy, because of adverse effects that are not actually part of the biological effect of treatment. In extreme cases, as a result of suggestions and expectations, a paradoxical effect, biologically opposite to the mechanism of the action of the drug, may occur. In addition, the nocebo effect may significantly interfere with the results of clinical trials, being the cause of a significant proportion of complications reported. Knowledge of the phenomenon is thus necessary in order to facilitate its minimalization and thus improve the quality of life of patients and the effectiveness of treatment.

Precision Medicine and Personalized Management of Lipoprotein and Lipid Disorders in Chronic and End-Stage Kidney Disease

Precision medicine is an emerging field that calls for individualization of treatment strategies based on characteristics unique to each patient. In lipid management, current guidelines are driven mainly by clinical trial results that presently indicate that patients with non-dialysis-dependent chronic kidney disease (CKD) should be treated with a β-hydroxy β-methylglutaryl-CoA reductase inhibitor, also known as statin therapy. For patients with end-stage kidney disease (ESKD) being treated with hemodialysis, statin therapy has not been shown to successfully reduce poor outcomes in trials and therefore is not recommended. The two major guidelines dissent on whether statin therapy should be of moderate or high intensity in non-dialysis-dependent CKD patients, but often leave the prescribing clinician to make that decision. These decisions often are complicated by the increased concerns for adverse events such as myopathies in patients with advanced kidney disease and ESKD. In the future, there may be an opportunity to further identify CKD and ESKD patients who are more likely to benefit from lipid-modifying therapy as opposed to those who likely will suffer from its side effects using precision medicine tools. For now, data from genetics studies and subgroup analyses may provide insight for future research directions in this field and we review some of the work that has been published in this regard.

Patterns of statin utilisation for new users and market dynamics in South Korea: a 13-year retrospective cohort study

OBJECTIVE

This study analysed utilisation of statins for new statin users and assessed market dynamics of statins in South Korea.

DESIGN

This study is a retrospective cohort study.

SETTING

The yearly claims data for statins were retrieved from the National Health Insurance Service-National Sample Cohort.

MAIN OUTCOME MEASURE

We are interested in new statin users during 2003-2015 in Korea. Information on prescribed statins, including intensity of statins and entry of new and follow-on statins in the market, and healthcare institutions that prescribed the statins were also collected. In time series analysis, we estimated the effect of introduction of generics in the market, specifically for newly prescribed statin users.

RESULTS

This 13-year longitudinal study of a sample cohort provided by the National Health Insurance Service found that the incidence of new statin user increase from 838.1/100 000 persons in 2003 to 1626.9/100 000 persons in 2015. Most new users were initiated on a monotherapy that was prescribed at primary healthcare institutions. However, the statin market for new users were quite dynamic in Korea. First, the most commonly prescribed statin changed several times during the study period. Second, the use of moderate-intensity statins increased from 57% in 2003 to 92% in 2015. In line with this result, we could not observe substantial differences in prescription of statins in groups having selected diseases history. Lastly, we found market invasion or switch of statins among new statin users, specifically at primary healthcare institutions.

CONCLUSION

Similar to other countries, the incidence of new statin users has been increased in Korea. However, the statin market in Korea is quite dynamic compared with other countries. Interestingly, discounted price of originals after the introduction of generics immediately expand markets or substitute the market particularly in primary healthcare institutions in Korea.

The possible harms of statins: What do product labels, patient package inserts, and pharmacy leaflets tell us?

OBJECTIVES

To evaluate the degree to which health care professionals and patients receive consistent messages regarding the possible harms of statins.

DESIGN

Cross-sectional study of prescribing information (PI), patient package inserts (PPIs), and pharmacy leaflets for 8 statins approved by the U.S. Food and Drug Adminstration.

SETTING

Not applicable.

PARTICIPANTS

Not applicable.

MAIN OUTCOME MEASURES

All passages describing 7 adverse events (diarrhea, arthralgia, dyspepsia, confusion, memory loss, rhabdomyolysis, and kidney failure) were extracted from PIs, PPIs, and pharmacy leaflets. For each type of information source and adverse event (drug-harm pair), 2 reviewers independently judged passages as indicating either a confirmed, unconfirmed, or mixed causal relationship between statin and adverse event (drug-harm pair). Disagreements were resolved through consensus, and the consistency between information sources was calculated.

RESULTS

PI and PPI consistently conveyed the relationship between a given statin and given adverse event (either both "confirmed" or both "unconfirmed") in 12 of 17 evaluable drug-harm pairs. PPIs and pharmacy leaflets were consistent in 10 of 10 evaluable drug-harm pairs. PIs indicated a confirmed, causal relationship in 15 drug-harm pairs that were not mentioned in pharmacy leaflets. Likewise, PPIs indicated a confirmed, causal relationship in 7 drug-harm pairs that were not listed in pharmacy leaflets.

CONCLUSION

Despite the widespread use of statins, we discovered considerable ambiguity in language used to describe the evidence concerning their possible harms and variable consistency between PIs, PPIs, and pharmacy leaflets. Further study is needed to understand the reason why pharmacy leaflets did not list, in 15 cases, adverse events that PIs indicated were causally related to the statin.

Systematic review of the predictors of statin adherence for the primary prevention of cardiovascular disease

INTRODUCTION

Previous research has shown that statin adherence for the primary prevention of CVD is lower compared to secondary prevention populations. Therefore the aim of this systematic review was to review predictors of statin adherence for the primary prevention of CVD.

METHODS

A systematic search of papers published between Jan 1984 and May 2017 was conducted in PubMed, PsycINFO, EMbase and CINAHL databases. A study was eligible for inclusion if; 1) it was a study of the general population or of patients with familial hypercholesterolemia, hypertension, diabetes or arthritis; 2) statins were prescribed; 3) adherence was defined and measured as the extent to which patients followed their statin regimen during the period of prescription, and 4) it was an original trial or observational study (excluding case reports). A study was subsequently excluded if 1) results were not presented separately for primary prevention; 2) it was a trial of an intervention (for example patient education). Papers were reviewed by two researchers and consensus agreed with a third. A quality assessment (QA) tool was used to formally assess each included article. To evaluate the effect of predictors, data were quantitatively and qualitatively synthesised.

RESULTS

In total 19 studies met the inclusion criteria and nine were evaluated as high quality using the QA tool. The proportion of patients classed as "adherent" ranged from 17.8% to 79.2%. Potential predictors of statin adherence included traditional risk factors for CVD such as age, being male, diabetes and hypertension. Income associated with adherence more strongly in men than women, and highly educated men were more likely and highly educated women less likely to be adherent. Alcohol misuse and high BMI associated with non-adherence. There was no association between polypharmacy and statin adherence. The evidence base for the effect of other lifestyle factors and health beliefs on statin adherence was limited.

CONCLUSION

Current evidence suggests that patients with more traditional risk factors for CVD are more likely to be adherent to statins. The implications for future research are discussed.

Psychobiological Mechanisms of Placebo and Nocebo Effects: Pathways to Improve Treatments and Reduce Side Effects

Placebo effects constitute a major part of treatment success in medical interventions. The nocebo effect also has a major impact, as it accounts for a significant proportion of the reported side effects for many treatments. Historically, clinical trials have aimed to reduce placebo effects; however, currently, there is interest in optimizing placebo effects to improve existing treatments and in examining ways to minimize nocebo effects to improve clinical outcome. To achieve these aims, a better understanding of the psychological and neurobiological mechanisms of the placebo and nocebo response is required. This review discusses the impact of the placebo and nocebo response in health care. We also examine the mechanisms involved in the placebo and nocebo effects, including the central mechanism of expectations. Finally, we examine ways to enhance placebo effects and reduce the impact of the nocebo response in clinical practice and suggest areas for future research.

The efficacy of 'static' training interventions for improving indices of cardiorespiratory fitness in premenopausal females

PURPOSE

Cardiovascular disease (CVD) is the leading cause of death worldwide. Many risk factors for CVD can be modified pharmacologically; however, uptake of medications is low, especially in asymptomatic people. Exercise is also effective at reducing CVD risk, but adoption is poor with time-commitment and cost cited as key reasons for this. Repeated remote ischaemic preconditioning (RIPC) and isometric handgrip (IHG) training are both inexpensive, time-efficient interventions which have shown some promise in reducing blood pressure (BP) and improving markers of cardiovascular health and fitness. However, few studies have investigated the effectiveness of these interventions in premenopausal women.

METHOD

Thirty healthy females were recruited to twelve supervised sessions of either RIPC or IHG over 4 weeks, or acted as non-intervention controls (CON). BP measurements, flow-mediated dilatation (FMD) and cardiopulmonary exercise tests (CPET) were performed at baseline and after the intervention period.

RESULTS

IHG and RIPC were both well-tolerated with 100% adherence to all sessions. A statistically significant reduction in both systolic (- 7.2 mmHg) and diastolic (- 6 mmHg) BP was demonstrated following IHG, with no change following RIPC. No statistically significant improvements were observed in FMD or CPET parameters in any group.

CONCLUSIONS

IHG is an inexpensive and well-tolerated intervention which may improve BP; a key risk factor for CVD. Conversely, our single arm RIPC protocol, despite being similarly well-tolerated, did not elicit improvements in any cardiorespiratory parameters in our chosen population.

Introducing the 'Drucebo' effect in statin therapy: a systematic review of studies comparing reported rates of statin-associated muscle symptoms, under blinded and open-label conditions

BACKGROUND

The 'placebo effect' and 'nocebo effect' are phenomena whereby beneficial (placebo) or adverse (nocebo) effects result from the expectation that an inert substance will relieve or cause a particular symptom. These terms are often inappropriately applied to effects experienced on drug therapy. Quantifying the magnitude of placebo and nocebo effects in clinical trials is problematic because it requires a 'no treatment' arm. To overcome the difficulties associated with measuring the nocebo effect, and the fact that its definition refers to inert compounds, rather than drugs, we introduce the concept of 'drucebo' (a combination of DRUg and plaCEBO or noCEBO) to relate to beneficial or adverse effects of a drug, which result from expectation and are not pharmacologically caused by the drug. As an initial application of the concept, we have estimated the contribution of the drucebo effect to statin discontinuation and statin-induced muscle symptoms by performing a systematic review of randomized controlled trial of statin therapy.

METHODS

This preferred reporting items for systematic reviews and meta-analysis-compliant systematic review was prospectively registered in PROSPERO (CRD42017082700). We searched PubMed and Cochrane Central from inception until 3 January 2018 using a search strategy designed to detect studies including the concepts (Statins AND Placebo AND muscle pain). We included studies that allowed us to quantify the drucebo effect for adverse muscle symptoms of statins by (i) comparing reported rates of muscle symptoms in blinded and unblinded phases of randomized controlled trials and (ii) comparing rates of muscle symptoms at baseline and during blinded therapy in trials that included patients with objectively confirmed statin intolerance at baseline. Extraction was performed by two researchers with disagreements settled by a third reviewer.

RESULTS

Five studies allowed the estimation of the drucebo effect. All trials demonstrated an excess of side effects under open-label conditions. The contribution of the drucebo effect to statin-associated muscle pain ranged between 38% and 78%. The heterogeneity of study methods, outcomes, and reporting did not allow for quantitative synthesis (meta-analysis) of the results.

CONCLUSIONS

The drucebo effect may be useful in evaluating the safety and efficacy of medicines. Diagnosis of the drucebo effect in patients presenting with statin intolerance will allow restoration of life-prolonging lipid-lowering therapy. Our study was limited by heterogeneity of included studies and lack of access to individual patient data. Further studies are necessary to better understand risk factors for and clinical management of the drucebo effect.

Association Between Statin Use and Prevalence of Exercise-Related Injuries: A Cross-Sectional Survey of Amateur Runners in the Netherlands

Background

HMG-CoA reductase inhibitors (statins) are the first-choice therapy for primary prevention of cardiovascular disease. Some maintain that statins cause adverse musculoskeletal outcomes in highly active individuals, but few studies have examined the effects of statins on exercise-related injuries.

Objective

We sought to compare the prevalence of exercise-related injuries between runners who do or do not use statins.

Methods

Amateur runners (n = 4460) completed an extensive online questionnaire on their exercise patterns and health status. Participants replied to questions on the prevalence of exercise-related injuries in the previous year. Injuries were divided into general injuries, tendon- and ligament-related injuries, and muscle-related injuries. Participants were also queried about statin use: the type of statin, statin dose, and duration of treatment. Runners were divided into statin users, non-statin users with hypercholesterolemia, and controls for analysis.

Results

The crude odds ratios (ORs) for injuries, tendon- or ligament-related injuries, and muscle-related injuries in statin users compared with controls were 1.14 (95% confidence interval [CI] 0.79–1.66), 1.10 (95% CI 0.71–1.72), and 1.15 (95% CI 0.69–1.91), respectively. After adjustment for age, sex, body mass index (BMI), and metabolic equivalent of task (MET) h/week of exercise, the ORs were 1.11 (95% CI 0.76–1.62), 1.06 (95% CI 0.68–1.66), and 0.98 (95% CI 0.58–1.64), respectively. Similar effect measures were found when comparing non-statin users with hypercholesterolemia and controls.

Conclusion

We did not find an association between statin use and the prevalence of exercise-related injuries or tendon-, ligament-, and muscle-related injuries. Runners receiving statins should continue normal physical activity without concern for increased risk of injuries.

Implications of True and Perceived Treatment Burden on Cardiovascular Medication Use

Background: Clinical decisions require weighing possible risks and benefits, which are often based on the provider's sense of treatment burden. Patients often have a different view of how heavily treatment burden should be weighted. Objective: To examine how much small variations in patient treatment burden would influence optimal use of antihypertensive medications and how much over- and undertreatment can result from clinicians misunderstanding their patients' values. Methods: Analysis-Markov chain model. Data sources-Existing literature, including an individual-level meta-analysis of blood pressure trials. Target population-US representative sample, ages 40 to 85, no history of cardiovascular disease. Time horizon-Effect of 10 years of treatment on estimated lifetime quality-adjusted life-year (QALY) burden. Perspective-Patient.

OUTCOME MEASURES

QALYs gained by treatment. Results: Fairly small differences in true patient burden from blood pressure treatment alter the number of blood pressure medications that should be recommended and alters treatment's potential benefit dramatically. We also found that a clinician misunderstanding the patient's burden could lead to almost 30% of patients being treated inappropriately. Limitations: Our results are based on simulation modeling. Conclusions: Clinical decisions that fail to account for patient treatment burden can mistreat a very large proportion of the public. Successful treatment choices closely depend on a clinician's ability to accurately gauge a patient's treatment burden.

The Power of Labeling in Nocebo Effects

Nocebo effects comprise two broad types: primary nocebo effects, in which overall treatment efficacy is reduced; and nocebo side effects, which result in the increased experience of unpleasant secondary side effects. An important factor in generating nocebo effects of both types is the patient's expectations of how well a treatment will work, and how likely it is to cause side effects. One source of negative expectations is the presence of generic-as opposed to brand name-labeling. A medicine's labeling is likely to be one of the first aspects of a treatment that is encountered by a patient, and perhaps the most common labeling information on pharmaceuticals is the labeling that identifies the drug as being made by the originator brand manufacturer, or as a generic copy. Although generic medicines are pharmaceutically equivalent to their brand name counterparts, generics are often viewed with distrust and perceived to be inferior to branded medicines. Negative perceptions of generic pharmaceuticals may contribute to reduced treatment efficacy via enhanced primary nocebo effects, and increased nocebo side effects. This chapter reviews evidence for the role of brand and generic labeling in treatment outcomes across a range of contexts-most often laboratory research assessing pain outcomes, as well as the influence of related factors including price, familiarity, and treatment switches. Although increasing evidence suggests that labeling of medicines can shape nocebo effects, interventions to improve perceptions of generics do not necessarily translate into more positive treatment outcomes.

Adverse events with botulinum toxin treatment in cervical dystonia: How much should we blame placebo?

INTRODUCTION

Botulinum toxin (BoNT) is the first line therapy for cervical dystonia (CD), with most patients receiving many treatment sessions, and so come to recognize and expect the benefits and harms of BoNT, making it difficult to separate which adverse events (AEs) are driven by BoNT and which come from patients' expectations.

METHODS

Using the results of three Cochrane systematic reviews of randomized controlled trials (RCTs) we pooled results to calculate the risk of general and specific AEs associated with BoNT, and the proportion of AEs that cannot be pharmacologically attributed to BoNT.

RESULTS

Fifteen RCTs, enrolling 1604 patients, were included. BoNT was associated with an increased risk of AEs, but 79% of this increased risk cannot be pharmacologically attributed to BoNT.

CONCLUSIONS

Patients with CD attach a considerable expectation of harm due to BoNT, reflected in the large proportion of non-pharmacologically-mediated AEs.

A protocol for an economic evaluation of a polypill in patients with established or at high risk of cardiovascular disease in a UK NHS setting: RUPEE (NHS) study

INTRODUCTION

The 'Use of a Multi-drug Pill in Reducing cardiovascular Events' (UMPIRE) trial was a randomised controlled clinical trial evaluating the impact of a polypill strategy on adherence to indicated medication in a population with established cardiovascular disease (CVD) of or at high risk thereof. The aim of Researching the UMPIRE Processes for Economic Evaluation in the National Health Service (RUPEE NHS) is to estimate the potential health economic impact of a polypill strategy for CVD prevention within the NHS using UMPIRE trial and other relevant data. This paper describes the design of a modelled economic evaluation of the impact of increased adherence to the polypill versus usual care among the UK UMPIRE participants.

METHODS AND ANALYSIS

As recommended by the International Society for Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making modelling guidelines, a review of published CVD models was undertaken to identify the most appropriate modelling approach and structure. The review was carried out in the electronic databases, MEDLINE and EMBASE. 40 CVD models were identified from 57 studies, the majority of economic models were health state transition cohort models and individual-level simulation models. The findings were discussed with clinical experts to confirm the approach and structure. An individual simulation approach was identified as the most suitable method to capture the heterogeneity in the population at CVD risk. RUPEE-NHS will use UMPIRE trial data on adherence to estimate the long-term cost-effectiveness of the polypill strategy.

DISSEMINATION

The evaluation findings will be presented in open-access scientific and healthcare policy journals and at national and international conferences. We will also present findings to NHS policy makers and pharmaceutical companies.

Adjuvant Statin Therapy for Esophageal Adenocarcinoma: A Cost-Utility Analysis

BACKGROUND

Emerging preclinical evidence indicates statins, medications commonly used in the prevention of cardiovascular disease (CVD), inhibit proliferation, promote apoptosis and limit invasiveness of esophageal adenocarcinoma (EAC). Population-based observational data demonstrate statin treatment after diagnosis of EAC is associated with significant reductions in all-cause and cancer-specific mortality. A feasibility study of adjuvant statin therapy following potentially curative resection for EAC has been completed, with planned progression to a full phase III, randomized controlled trial.

OBJECTIVE

The aim was to estimate the cost-utility of statin therapy following surgical resection for EAC from a UK National Health Service (NHS) perspective.

METHODS

A Markov model was developed to estimate the costs and outcomes [quality-adjusted life years (QALYs)] for hypothetical cohorts of patients with EAC exposed or not exposed to statins following potentially curative surgical resection. Model parameters were based on estimates from published observational and trial data. Costs, utilities and transition probabilities were modeled to reflect clinical practice from a payer's perspective. Probabilistic and one-way sensitivity analyses were performed to account for uncertainty in key parameters.

RESULTS

Overall, a cost saving of £6781 per patient was realized with statin treatment compared to no statins. In probabilistic sensitivity analysis, 99% of all iterations were cost saving and 99% of all iterations were less than £20,000 per QALY gained. These results were robust to changes in the price and effectiveness of statins.

CONCLUSIONS

The cohort exposed to statins had lower costs and better QALY outcomes than the no statin cohort. Assuming a causal improvement in disease outcomes following resection for EAC, statin therapy is very likely to be a cost-saving treatment.

Side effects and tolerability of combination blood pressure lowering according to blood pressure levels: an analysis of the PROGRESS and ADVANCE trials

OBJECTIVE

To measure the placebo-controlled effects of combination therapy on hypotension, treatment discontinuation, and major renal outcomes, according to baseline blood pressure.

METHODS

We conducted an analysis of the action in diabetes and vascular disease: preterax and diamicron-MR controlled evaluation ADVANCE and perindopril protection against recurrent stroke study PROGRESS trials, including 14 684 participants allocated combination therapy or placebo. The mean age was 65 years, 61% were men, and 64% were receiving background blood pressure lowering (BPL) therapy. Participants were stratified into five subgroups by baseline SBP less than 120, 120-129, 130-139, 140-159, and at least 160 mmHg. Discontinuation of study treatment during the active run-in phase and postrandomization follow-up was assessed for hypotension/dizziness and other causes. Major renal outcomes (sustained doubling in creatinine or renal death) were also assessed.

RESULTS

Discontinuation during the 4-6-week active run-in phase due to hypotension/dizziness ranged from 3.6% in those with SBP less than 120 mmHg to 1.3% in those with SBP at least 160 mmHg. Median follow-up in the randomized phase was 5.6 years, and discontinuation for hypotension was higher with combination therapy compared with placebo in the less than 120 mmHg group (4.7 vs. 1.2%). However, for each subgroup with baseline SBP 120-129, 130-139, and 140-159 mmHg, the absolute excess of discontinuation due to hypotension with combination therapy was 0.7%. Total discontinuations were only increased in the less than 120 mmHg group (18.4 vs. 12.5%) and the 120-129-mmHg subgroup (17.6 vs. 14.2%). There were no clear differences across the SBP subgroups for the combined renal outcome (overall, 0.8 vs. 0.6%).

CONCLUSION

Compared with those with baseline SBP 140-159 mmHg, side effects of dual combination BPL are essentially the same for people with SBP 130-139 mmHg and only modestly increased among patients with SBP 120-129 mmHg. During long-term therapy, side effects sufficient to stop treatment that are treatment related (i.e. occur in excess of rates seen with placebo) occur at less than 0.5%/year in patients with baseline SBP 120-139 mmHg. These results have important implications in assessing the likely balance of benefits and side effects of BPL with combination therapy among those with SBP 120-139 mmHg.

Study protocol for statin web-based investigation of side effects (StatinWISE): a series of randomised controlled N-of-1 trials comparing atorvastatin and placebo in UK primary care

INTRODUCTION

Statins are effective at preventing cardiovascular disease, widely prescribed and their use is growing. Uncertainty persists about whether they cause symptomatic muscle adverse effects, such as pain and weakness, in the absence of statin myopathy. Discrepancies between data from observational studies, which suggest statins are associated with excess muscle symptoms, and from randomised trials, which suggest no such excess, have caused confusion. N-of-1 trials offer the opportunity to establish whether muscle symptoms during statin use are caused by statins in particular individuals.

METHODS AND ANALYSIS

This series of 200 randomised, double-blinded N-of-1 trials in primary care will determine (1) the effect of statins on all muscle symptoms and (2) the effect of statins on muscle pain that is perceived to be statin related. Patients who are considering discontinuing statin use due to muscle symptoms and those who have discontinued in the last 3 years due to such symptoms will be recruited. Participants will be randomised to a sequence of six 2-month treatment periods during which they will receive atorvastatin 20 mg per day or matched placebo. On each of the last 7 days of each treatment period, participants will rate their muscle symptoms on a Visual Analogue Scale (VAS).At the end of their trial, participants will be shown numerical and graphical summaries of their own symptom data during statin and placebo periods. The primary analysis on the aggregate data from all participants will be a linear mixed model for VAS muscle symptom score, comparing scores during treatment with statin and placebo.

ETHICS AND DISSEMINATION

This trial received a favourable opinion from South Central-Hampshire A Research Ethics Committee. Results will be published in a peer-reviewed medical journal. Dissemination of results to patients will take place via the media, website (statinwise.lshtm.ac.uk) and patient organisations.

TRIAL REGISTRATION NUMBER

ISRCTN30952488.

A content analysis of the representation of statins in the British newsprint media

OBJECTIVE

This study reviewed the news media coverage of statins, seeking to identify specific trends or differences in viewpoint between media outlets and examine common themes.

DESIGN

The study is a content analysis of the frequency and content of the reporting of statins in a selection of the British newsprint media. It involved an assessment of the number, timing and thematic content of articles followed by a discourse analysis examining the underlying narratives. The sample was the output of four UK newspapers, covering a broad-spectrum readership, over a six month timeframe 1 October 2013 to 31 March 2014.

RESULTS

A total of 67 articles included reference to statins. The majority (39, 58%) were reporting or responding to publication of a clinical study. The ratio of negative to positive coverage was greater than 2:1 overall. In the more politically right-leaning newspapers, 67% of coverage was predominantly negative (30/45 articles); 32% in the more left-leaning papers (7/22 articles). Common themes were the perceived 'medicalisation' of the population; the balance between lifestyle modification and medical treatments in the primary prevention of heart disease; side effects and effectiveness of statins; pharmaceutical sponsorship and implications for the reliability of evidence; trust between the public and government, institutions, research organisations and the medical profession.

CONCLUSIONS

Newsprint media coverage of statins was substantially influenced by the publication of national guidance and by coverage in the medical journals of clinical studies and comment. Statins received a predominantly negative portrayal, notably in the more right-leaning press. There were shared themes: concern about the balance between medication and lifestyle change in the primary prevention of heart disease; the adverse effects of treatment; and a questioning of the reliability of evidence from research institutions, scientists and clinicians in the light of their potential allegiances and funding.

Associations of statin use with motor performance and myalgia may be modified by 25-hydroxyvitamin D: findings from a British birth cohort

The objective was to examine whether: (1) statin use was associated with muscle related outcomes at age 60-64, (2) these associations were modified by 25-hydroxyvitamin D (25(OH)D) status and explained by inflammation, body-size or lifestyle in a British birth cohort. Markers of myalgia (intrusive body pain) and myopathy (self-reported and performance-based measures) were examined in 734 men and 822 women (MRC National Survey of Health and Development). Statin use was associated with intrusive body pain, difficulty climbing stairs and slower chair rise speed. Some associations were modified by 25(OH)D e.g. the association with intrusive body pain was evident in the insufficient (13-20 ng/l) and deficient (<13 ng/l) 25(OH)D status groups (OR = 2.6,95% CI 1.7-1.1; OR = 1.8,95% CI 1.2-2.8, respectively) but not in those with status >20 ng/l (OR = 0.8,95% CI 0.5-1.4) (p = 0.003 for interaction). Associations were maintained in fully adjusted models of intrusive body pain and difficulty climbing stairs, but for chair rise speed they were fully accounted for by inflammation, body-size and lifestyle. In a nationally representative British population in early old age, statin use was associated with lower limb muscle-related outcomes, and some were only apparent in those with 25(OH)D status below 20 ng/l. Given 25(OH)D is modifiable in clinical practice, future studies should consider the links between 25(OH)D status and muscle related outcomes.

Development and Content Validity of the Statin Experience Assessment Questionnaire (SEAQ)©

INTRODUCTION

The National Lipid Association Statin Intolerance (SI) Panel recognized the need for better understanding of the patient SI experience.

OBJECTIVE

The objective of this research was to develop a patient-reported outcome (PRO) questionnaire to assess a patient's experience with SI.

METHODS

Questionnaire development was informed via a series of research activities: literature review, concept elicitation, item generation, and content evaluation. Following the literature review and concept elicitation, a draft questionnaire was constructed and subsequently modified based on feedback from therapeutic area experts and patients via cognitive debriefing interviews.

RESULTS

Muscle-related symptoms were the most commonly reported symptoms associated with SI in the literature review (35 of 41 articles reviewed [85%]) and in semi-structured interviews with experts (n = 5 [100%]) and patients (n = 17 of 20 [85.0%]). Physical and other impacts of SI symptoms on daily activities were also frequently reported. A 17-item draft questionnaire was created, and cognitive debriefing with experts (n = 5) and patients (n = 15) was conducted. Overall, the items, response options, and instructions were comprehensible and positively reviewed; minor changes resulted in the 15-item Statin Experience Assessment Questionnaire (SEAQ)©. Using a 30-day recall period, the SEAQ© assesses the severity and impact of six SI symptoms (muscle ache, muscle pain, muscle cramps, muscle weakness, tiredness, and joint pain) on an 11-point numeric scale. Statin discontinuation and likelihood of discontinuation due to symptoms are assessed and scored on a yes/no and five-point verbal response scale, respectively.

CONCLUSION

The SEAQ

Statin-induced calcific Achilles tendinopathy in rats: comparison of biomechanical and histopathological effects of simvastatin, atorvastatin and rosuvastatin

PURPOSE

Accumulating clinical evidence indicates the risk of tendinopathy and spontaneous and/or simultaneous tendon ruptures associated with statin use. This experimental study was designed to evaluate and compare the biomechanical and histopathological effects of the three most commonly prescribed statins (simvastatin, atorvastatin and rosuvastatin) on the Achilles tendon in rats.

METHODS

Statins were administered by gavage to rats at daily doses of 20 and 40 mg/kg for 3 weeks. One week later, the Achilles tendons were dissected and their biomechanical properties, including ultimate tensile force, yield force and elastic modulus, were determined. The samples were stained with haematoxylin-eosin and examined under a light microscope. The biomechanical properties of the tibia were tested by three-point bending test. Bone mineral density (BMD) and the lengths of tibias were measured by computed tomography.

RESULTS

All the statins caused deterioration of the biomechanical parameters of the Achilles tendon. Histopathological analysis demonstrated foci of dystrophic calcification only in the statin-treated groups. However, the number and the total area of calcific deposits were similar between the statin groups. The biomechanical parameters of tibias were improved in all the statin groups. BMD in the statin-treated groups was not significantly different from the control group.

CONCLUSION

All the statins tested are associated with calcific tendinopathy risk of which full awareness is required during everyday medical practice. However, statin-associated improvement of bone biomechanical properties is a favourable feature which may add to their beneficial effects in atherosclerotic cardiovascular disease, especially in the elderly.

Patterns of Statin Use in Older Medicare Beneficiaries With Traumatic Brain Injury

BACKGROUND

In addition to lowering lipids, statins also may be beneficial for older adults sustaining a traumatic brain injury (TBI), as statin use prior to and following trauma may decrease mortality following injury. However, despite statins' potential to reduce mortality, there is limited research regarding statin use among older adults.

OBJECTIVE

To characterize and investigate factors associated with statin use among older adults with TBI.

METHODS

A retrospective drug utilization study was used to characterize statin use among Medicare beneficiaries 65 and older hospitalized with a TBI during 2006 to 2010 and with continuous Medicare Parts A, B, and D coverage 6 months prior and 12 months following TBI. Logistic regression was used to investigate the factors associated with statin use. The exposure of interest was statin use prior to and following TBI.

RESULTS

Of the 75 698 beneficiaries included in the study, 37 874 (~50%) of beneficiaries used a statin at least once during the study period. The most common statin used was simvastatin, while fluvastatin was the least used statin. Statin users were more likely to have cardiovascular diseases when compared to nonusers. Hyperlipidemia was a major factor associated with statin use and had the greatest impact on statin use compared to nonuse (odds ratio = 9.54; 95% confidence interval = 9.07, 10.03).

CONCLUSIONS

This national sample of older adults with TBI suggests that statins are commonly used. Future studies must next examine the impact of statin use on mortality and secondary injury in order to shape pharmacological therapy guidelines following TBI.

10-year trends in statin utilization in Taiwan: a retrospective study using Taiwan's National Health Insurance Research Database

OBJECTIVE

Statins have been commonly used to treat patients with hypercholesterolaemia and to prevent cardiovascular disease (CVD) worldwide. This study examined trends in use of statins in Taiwan from 2002 to 2011.

DESIGN

This is a retrospective observational study focusing on the utilisation of statins.

SETTING

The monthly claims data for statins between 2002 and 2011 were retrieved from Taiwan's National Health Insurance Research Database.

MAIN OUTCOME MEASURES

We calculated the yearly prescription rate per new user for each statin. Products were classified as high-intensity/moderate-intensity/low-intensity statins by type of statin and dosage. Users were also classified based on disease histories.

RESULTS

The number of statin users increased from 10 299 (~1.4% of adults) in 2002 to 50 687 (~6.3% of adults) in 2011. Atorvastatin was the most commonly used agent (28.4%-36.7%) during the study period. After 2007, simvastatin ranked second with 21.7% market share, followed by rosuvastatin, a newer agent that exhibited a substantial growth in prescription rates (3.4% in 2005 and 19.5% in 2011). In 2011, 94.0% of new statin users used statin monotherapies, and 6.0% used combination therapies. Use of moderate-intensity statins increased from 49.0% in 2002 to 71.0% in 2011, while high-intensity statins remained low. Patients with history of coronary events or cerebrovascular events were more likely to be prescribed higher intensity statins compared with those without. Prescribing of higher intensity statins was not greater among people with diabetes compared with those without during 2007-2011. Selection of statins did not differ between people with versus without history of myopathy or liver injury.

CONCLUSION

Atorvastatin was the most commonly used statin in Taiwan during 2002-2011. While patients with history of CVD were more likely to be prescribed higher intensity statins compared with those without, this difference was not found comparing those with and without diabetes.

Statins and Lower Gastrointestinal Conditions: A Retrospective Cohort Study

Several studies have reported constipation, abdominal pain, or diarrhea as common adverse events for statins. Statins are among the most commonly prescribed medications, and the impact on the prevalence of these conditions was rarely studied as main outcomes. The aim of this study is to determine if statin therapy is associated with constipation, abdominal pain, diarrhea, or colitis. This was a retrospective cohort study using a regional military health care data from October 1, 2003, to March 1, 2012. A propensity score-matched cohort of statin users and nonusers was created based on 82 variables. The primary analysis evaluated the odds ratios of the following diagnoses: constipation, ≥3 encounters for constipation; abdominal pain, ≥3 encounters for abdominal pain; diarrhea, ≥3 encounters for diarrhea; colitis, ≥3 encounters for colitis; and endoscopy of the lower gastrointestinal tract, ≥3 endoscopies of the lower gastrointestinal tract. After propensity score matching of 6342 statin users and 6342 nonusers, there was no statistically significant difference in constipation (OR, 0.96; 95%CI, 0.87-1.05; P = .33), abdominal pain (OR, 0.95; 95%CI, 0.88-1.02; P = .15), or colitis (OR, 1.02; 95%CI, 0.91-1.14; P = .73). However, there was an association between statin therapy and endoscopy of the lower gastrointestinal tract (OR, 1.14; 95%CI, 1.04-1.26; P = .002) and decreased odds of diarrhea (OR, 0.88; 95%CI, 0.80-0.97; P = .01). In this retrospective cohort study, an association between statin therapy and increased likelihood of being diagnosed with lower gastrointestinal conditions could not be demonstrated, contrary to some statins package inserts.

Assessing potential population impact of statin treatment for primary prevention of atherosclerotic cardiovascular diseases in the USA: population-based modelling study

OBJECTIVE

New cholesterol treatment guidelines from American College of Cardiology/American Heart Association recommend statin treatment for more of US population to prevent atherosclerotic cardiovascular disease (ASCVD). It is important to assess how new guidelines may affect population-level health. This study assessed the impact of statin use for primary prevention of ASCVD under the new guidelines.

METHODS

We used data from 2010 US Multiple Cause Mortality, Third National Health and Nutrition Examination Survey (NHANES III) Linked Mortality File (1988-2006, n=8941) and NHANES 2005-2010 (n=3178) participants 40-75 years of age for the present study.

RESULTS

Among 33.0 million adults meeting new guidelines for primary prevention of ASCVD, 8.8 million were taking statins; 24.2 million, including 7.7 million with diabetes, are eligible for statin treatment. If all those with diabetes used a statin, 2514 (95% CI 592 to 4142) predicted ASCVD deaths would be prevented annually with 482 (0 to 2239) predicted annual additional cases of myopathy based on randomised clinical trials (RCTs), and 11 801 (9251 to 14 916) using population-based study. Among 16.5 million without diabetes, 5425 (1276 to 8935) ASCVD deaths would be prevented annually with 16 406 (4922 to 26 250) predicted annual additional cases of diabetes and between 1030 (0 to 4791) and 24 302 (19 363 to 30 292) additional cases of myopathy based on RCTs and population-based study. Assuming 80% eligible population take statins with 80% medication adherence, among those without diabetes, the corresponding numbers were 3472 (817 to 5718) deaths, 10 500 (3150 to 16 800) diabetes, 660 (0 to 3066) myopathy (RCTs), and 15 554 (12 392 to 19 387) myopathy (population-based). The estimated total annual cost of statins use ranged from US$1.65 to US$6.5 billion if 100% of eligible population take statins.

CONCLUSIONS

This population-based modelling study focused on impact of statin use on ASCVD mortality. Under the new guidelines, if all those eligible for primary prevention of ASCVD take statins, up to 12.6% of annual ASCVD deaths might be prevented, though additional cases of diabetes and myopathy likely occur.

DISCLAIMER

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Pharmacogenetic Foundations of Therapeutic Efficacy and Adverse Events of Statins

Background: In the era of precision medicine, more attention is paid to the search for predictive markers of treatment efficacy and tolerability. Statins are one of the classes of drugs that could benefit from this approach because of their wide use and their incidence of adverse events. Methods: Literature from PubMed databases and bibliography from retrieved publications have been analyzed according to terms such as statins, pharmacogenetics, epigenetics, toxicity and drug–drug interaction, among others. The search was performed until 1 October 2016 for articles published in English language. Results: Several technical and methodological approaches have been adopted, including candidate gene and next generation sequencing (NGS) analyses, the latter being more robust and reliable. Among genes identified as possible predictive factors associated with statins toxicity, cytochrome P450 isoforms, transmembrane transporters and mitochondrial enzymes are the best characterized. Finally, the solute carrier organic anion transporter family member 1B1 (SLCO1B1) transporter seems to be the best target for future studies. Moreover, drug–drug interactions need to be considered for the best approach to personalized treatment. Conclusions: Pharmacogenetics of statins includes several possible genes and their polymorphisms, but muscular toxicities seem better related to SLCO1B1 variant alleles. Their analysis in the general population of patients taking statins could improve treatment adherence and efficacy; however, the cost–efficacy ratio should be carefully evaluated.

Statin Use and Self-Reported Hindering Muscle Complaints in Older Persons: A Population Based Study

Purpose

Statins are widely used by older persons in primary and secondary prevention of cardiovascular disease. Although serious adverse events are rare, many statin users report mild muscle pain and/or muscle weakness. It’s unclear what impact statins exert on a patient’s daily life. Research on statin related side effects in older persons is relatively scarce. We therefore investigated the relation between statin use and self-reported hindering muscle complaints in older persons in the general population.

Methods

The present research was performed within the Integrated Systematic Care for Older Persons (ISCOPE) study in the Netherlands (Netherlands trial register, NTR1946). All registered adults aged ≥ 75 years from 59 participating practices (n = 12,066) were targeted. Information about the medical history and statin use at baseline and after 9 months was available for 4355 participants from the Electronic Patient Records of the general practitioners. In the screening questionnaire at baseline we asked participants: ‘At the moment, which health complaints limit you the most in your day-to-day life?’ Answers indicating muscle or musculoskeletal complaints were coded as such. No specific questions about muscle complaints were asked.

Results

The participants had a median age of 80.3 (IQR 77.6–84.4) years, 60.8% were female and 28.5% had a history of CVD. At baseline 29% used a statin. At follow-up, no difference was found in the prevalence of self-reported hindering muscle complaints in statin users compared to non-statin users (3.3% vs. 2.5%, OR 1.39, 95% CI 0.94–2.05; P = 0.98). Discontinuation of statin use during follow-up was independent of self-reported hindering muscle complaints.

Conclusion

Based on the present findings, prevalent statin use in this community-dwelling older population is not associated with self-reported hindering muscle complaints; however, the results might be different for incident users.

Statins in Primary Prevention: Uncertainties and Gaps in Randomized Trial Data

Randomized controlled trials (RCTs) have provided evidence of the usefulness of statin primary prevention in lowering cardiovascular morbidity and mortality, yet uncertainties and gaps remain. The objective of this article was to perform a narrative review of RCTs of statins for primary prevention and identify uncertainties and gaps resulting from the design of individual studies. Such knowledge is important for informed physician-patient decisions. A literature search was conducted for RCTs of statins in primary prevention that included >1000 general patients and clinical outcomes as a primary endpoint. A total of 11 RCTs were identified; target population baseline characteristics, outcomes measures, statistical methods, and limitations regarding follow-up were reported. RCTs of statins in primary prevention show consistent overall beneficial effects on cardiovascular morbidity and mortality. Caveats involve the characteristics of individual study populations since target populations often differ from what is currently considered primary prevention. Only middle aged and older populations were adequately represented in these RCTs; women were under-represented. Only one study included total mortality as the primary endpoint; all other RCTs used composite major adverse cardiac events as the primary endpoint, which occasionally included a hard outcome such as death and a soft outcome such as hospitalization for angina. The use of Cox proportional hazard analysis in RCTs poses some challenges, and intention-to-treat analysis may mask adverse events. An understanding of the deficiencies of individual RCTs of statins in primary prevention is important in creating a patient-specific therapeutic clinical decision and in tailoring future research.

Interpretation of the evidence for the efficacy and safety of statin therapy

This Review is intended to help clinicians, patients, and the public make informed decisions about statin therapy for the prevention of heart attacks and strokes. It explains how the evidence that is available from randomised controlled trials yields reliable information about both the efficacy and safety of statin therapy. In addition, it discusses how claims that statins commonly cause adverse effects reflect a failure to recognise the limitations of other sources of evidence about the effects of treatment. Large-scale evidence from randomised trials shows that statin therapy reduces the risk of major vascular events (ie, coronary deaths or myocardial infarctions, strokes, and coronary revascularisation procedures) by about one-quarter for each mmol/L reduction in LDL cholesterol during each year (after the first) that it continues to be taken. The absolute benefits of statin therapy depend on an individual's absolute risk of occlusive vascular events and the absolute reduction in LDL cholesterol that is achieved. For example, lowering LDL cholesterol by 2 mmol/L (77 mg/dL) with an effective low-cost statin regimen (eg, atorvastatin 40 mg daily, costing about £2 per month) for 5 years in 10 000 patients would typically prevent major vascular events from occurring in about 1000 patients (ie, 10% absolute benefit) with pre-existing occlusive vascular disease (secondary prevention) and in 500 patients (ie, 5% absolute benefit) who are at increased risk but have not yet had a vascular event (primary prevention). Statin therapy has been shown to reduce vascular disease risk during each year it continues to be taken, so larger absolute benefits would accrue with more prolonged therapy, and these benefits persist long term. The only serious adverse events that have been shown to be caused by long-term statin therapy-ie, adverse effects of the statin-are myopathy (defined as muscle pain or weakness combined with large increases in blood concentrations of creatine kinase), new-onset diabetes mellitus, and, probably, haemorrhagic stroke. Typically, treatment of 10 000 patients for 5 years with an effective regimen (eg, atorvastatin 40 mg daily) would cause about 5 cases of myopathy (one of which might progress, if the statin therapy is not stopped, to the more severe condition of rhabdomyolysis), 50-100 new cases of diabetes, and 5-10 haemorrhagic strokes. However, any adverse impact of these side-effects on major vascular events has already been taken into account in the estimates of the absolute benefits. Statin therapy may cause symptomatic adverse events (eg, muscle pain or weakness) in up to about 50-100 patients (ie, 0·5-1·0% absolute harm) per 10 000 treated for 5 years. However, placebo-controlled randomised trials have shown definitively that almost all of the symptomatic adverse events that are attributed to statin therapy in routine practice are not actually caused by it (ie, they represent misattribution). The large-scale evidence available from randomised trials also indicates that it is unlikely that large absolute excesses in other serious adverse events still await discovery. Consequently, any further findings that emerge about the effects of statin therapy would not be expected to alter materially the balance of benefits and harms. It is, therefore, of concern that exaggerated claims about side-effect rates with statin therapy may be responsible for its under-use among individuals at increased risk of cardiovascular events. For, whereas the rare cases of myopathy and any muscle-related symptoms that are attributed to statin therapy generally resolve rapidly when treatment is stopped, the heart attacks or strokes that may occur if statin therapy is stopped unnecessarily can be devastating.

Statins for Prevention of Cardiovascular Disease in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Cardiovascular disease (CVD), the leading cause of mortality and morbidity in the United States, may be potentially preventable with statin therapy.

OBJECTIVE

To systematically review benefits and harms of statins for prevention of CVD to inform the US Preventive Services Task Force.

DATA SOURCES

Ovid MEDLINE (from 1946), Cochrane Central Register of Controlled Trials (from 1991), and Cochrane Database of Systematic Reviews (from 2005) to June 2016.

STUDY SELECTION

Randomized clinical trials of statins vs placebo, fixed-dose vs titrated statins, and higher- vs lower-intensity statins in adults without prior cardiovascular events.

DATA EXTRACTION AND SYNTHESIS

One investigator abstracted data, a second checked data for accuracy, and 2 investigators independently assessed study quality using predefined criteria. Data were pooled using random-effects meta-analysis.

MAIN OUTCOMES AND MEASURES

All-cause mortality, CVD-related morbidity or mortality, and harms.

RESULTS

Nineteen trials (n = 71 344 participants [range, 95-17 802]; mean age, 51-66 years) compared statins vs placebo or no statin. Statin therapy was associated with decreased risk of all-cause mortality (risk ratio [RR], 0.86 [95% CI, 0.80 to 0.93]; I2 = 0%; absolute risk difference [ARD], -0.40% [95% CI, -0.64% to -0.17%]), cardiovascular mortality (RR, 0.69 [95% CI, 0.54 to 0.88]; I2 = 54%; ARD, -0.43% [95% CI, -0.75% to -0.11%]), stroke (RR, 0.71 [95% CI, 0.62 to 0.82]; I2 = 0; ARD, -0.38% [95% CI, -0.53% to -0.23%]), myocardial infarction (RR, 0.64 [95% CI, 0.57 to 0.71]; I2 = 0%; ARD, -0.81% [95% CI, -1.19 to -0.43%]), and composite cardiovascular outcomes (RR, 0.70 [95% CI, 0.63 to 0.78]; I2 = 36%; ARD, -1.39% [95% CI, -1.79 to -0.99%]). Relative benefits appeared consistent in demographic and clinical subgroups, including populations without marked hyperlipidemia (total cholesterol level <200 mg/dL); absolute benefits were higher in subgroups at higher baseline risk. Statins were not associated with increased risk of serious adverse events (RR, 0.99 [95% CI, 0.94 to 1.04]), myalgias (RR, 0.96 [95% CI, 0.79 to 1.16]), or liver-related harms (RR, 1.10 [95% CI, 0.90 to 1.35]). In pooled analysis, statins were not associated with increased risk of diabetes (RR, 1.05 [95% CI, 0.91 to 1.20]), although statistical heterogeneity was present (I2 = 52%), and 1 trial found high-intensity statins associated with increased risk (RR, 1.25 [95% CI, 1.05 to 1.49]). No trial directly compared titrated vs fixed-dose statins, and there were no clear differences based on statin intensity.

CONCLUSIONS AND RELEVANCE

In adults at increased CVD risk but without prior CVD events, statin therapy was associated with reduced risk of all-cause and cardiovascular mortality and CVD events, with greater absolute benefits in patients at greater baseline risk.

Under-prescribing of Prevention Drugs and Primary Prevention of Stroke and Transient Ischaemic Attack in UK General Practice: A Retrospective Analysis

BACKGROUND

Stroke is a leading cause of death and disability; worldwide it is estimated that 16.9 million people have a first stroke each year. Lipid-lowering, anticoagulant, and antihypertensive drugs can prevent strokes, but may be underused.

METHODS AND FINDINGS

We analysed anonymised electronic primary care records from a United Kingdom (UK) primary care database that covers approximately 6% of the UK population. Patients with first-ever stroke/transient ischaemic attack (TIA), ≥18 y, with diagnosis between 1 January 2009 and 31 December 2013, were included. Drugs were considered under-prescribed when lipid-lowering, anticoagulant, or antihypertensive drugs were clinically indicated but were not prescribed prior to the time of stroke or TIA. The proportions of strokes or TIAs with prevention drugs under-prescribed, when clinically indicated, were calculated. In all, 29,043 stroke/TIA patients met the inclusion criteria; 17,680 had ≥1 prevention drug clinically indicated: 16,028 had lipid-lowering drugs indicated, 3,194 anticoagulant drugs, and 7,008 antihypertensive drugs. At least one prevention drug was not prescribed when clinically indicated in 54% (9,579/17,680) of stroke/TIA patients: 49% (7,836/16,028) were not prescribed lipid-lowering drugs, 52% (1,647/3,194) were not prescribed anticoagulant drugs, and 25% (1,740/7,008) were not prescribed antihypertensive drugs. The limitations of our study are that our definition of under-prescribing of drugs for stroke/TIA prevention did not address patients' adherence to medication or medication targets, such as blood pressure levels.

CONCLUSIONS

In our study, over half of people eligible for lipid-lowering, anticoagulant, or antihypertensive drugs were not prescribed them prior to first stroke/TIA. We estimate that approximately 12,000 first strokes could potentially be prevented annually in the UK through optimal prescribing of these drugs. Improving prescription of lipid-lowering, anticoagulant, and antihypertensive drugs is important to reduce the incidence and burden of stroke and TIA.

Big Data Cohort Extraction to Facilitate Machine Learning to Improve Statin Treatment

Health care Big Data studies hold substantial promise for improving clinical practice. Among analytic tools, machine learning (ML) is an important approach that has been widely used by many industries for data-driven decision support. In Big Data, thousands of variables and millions of patient records are commonly encountered, but most data elements cannot be directly used to support decision making. Although many feature-selection tools can help identify relevant data, these tools are typically insufficient to determine a patient data cohort to support learning. Therefore, domain experts with nursing or clinic knowledge play critical roles in determining value criteria or the type of variables that should be included in the patient cohort to maximize project success. We demonstrate this process by extracting a patient cohort (37,506 individuals) to support our ML work (i.e., the production of a proactive strategy to prevent statin adverse events) from 130 million de-identified lives in the OptumLabs™ Data Warehouse.

Statin intolerance - a question of definition

INTRODUCTION

Statin therapy is the backbone of pharmacologic therapy for low-density lipoproteins cholesterol lowering and plays a pivotal role in cardiovascular disease prevention. Statin intolerance is understood as the inability to continue using a statin to reduce individual cardiovascular risk sufficiently, due to the development of symptoms or laboratory abnormalities attributable to the initiation or dose escalation of a statin. Muscle symptoms are the most common side effects observed. Areas covered: The main aim of this article is to present a review on published definitions of statin intolerance. In addition, a brief review on clinical aspects and risk factors of statin intolerance is provided and features for a common definition for statin intolerance are suggested. Expert opinion: A definition of statin intolerance by major drug regulatory agencies is not available. In clinical studies, different definitions are chosen and results are not comparable; different medical associations do not agree on one common definition. There is an unmet need to establish a common definition of statin intolerance to ensure an appropriate clinical use of this important drug class. Further work is required to develop a consensus definition on statin intolerance that could have significant positive impact on both research and clinical management.

Development and Validation of Algorithms to Identify Statin Intolerance in a US Administrative Database

OBJECTIVES

To develop and validate algorithms to define statin intolerance (SI) in an administrative database using electronic medical records (EMRs) as the reference comparison.

METHODS

One thousand adults with one or more qualifying changes in statin therapy and one or more previous diagnoses of hyperlipidemia, hypercholesterolemia, or mixed dyslipidemia were identified from the Henry Ford Health System administrative database. Data regarding statin utilization, comorbidities, and adverse effects were extracted from the administrative database and corresponding EMR. Patients were stratified by cardiovascular (CV) risk. SI was classified as absolute intolerance or titration intolerance on the basis of changes in statin utilization and/or the occurrence of adverse effects and laboratory testing for creatine kinase. Measures of concordance (Cohen's kappa [κ]) and accuracy (sensitivity, specificity, positive predictive value [PPV], and negative predictive value) were calculated for the administrative database algorithms.

RESULTS

Half of the sample population was white, 52.9% were women, mean age was 60.6 years, and 35.7% were at high CV risk. SI was identified in 11.5% and 14.0%, absolute intolerance in 2.2% and 3.1%, and titration intolerance in 9.7% and 11.8% of the patients in the EMR and the administrative database, respectively. The algorithm identifying any SI had substantial concordance (κ = 0.66) and good sensitivity (78.1%), but modest PPV (64.0%). The titration intolerance algorithm performed better (κ = 0.74; sensitivity 85.4%; PPV 70.1%) than the absolute intolerance algorithm (κ = 0.40; sensitivity 50%; PPV 35.5%) and performed best in the high CV-risk group (n = 353), with robust concordance (κ = 0.73) and good sensitivity (80.9%) and PPV (75.3%).

CONCLUSIONS

Conservative but comprehensive algorithms are available to identify SI in administrative databases for application in real-world research. These are the first validated algorithms for use in administrative databases available to decision makers.

Low use of statins for secondary prevention in primary care: a survey in a northern Swedish population

Background

Cholesterol-lowering therapy with statins is recommended in established cardiovascular disease (CVD) and should be considered for patients at high cardiovascular risk. We surveyed statin treatment before first-time myocardial infarction in clinical practice compared to current guidelines, in patients with and without known CVD in primary care clinics with general practitioners (GPs) on short-term contracts vs. permanent staff GPs.

Methods

A total of 931 patients (345 women) in northern Sweden were enrolled in the study between November 2009 and December 2014 and stratified by prior CVD, comprising angina pectoris, revascularisation, ischaemic stroke or transitory ischaemic attack, or peripheral artery disease. Primary care clinics were classified by the proportion of GP salaries that were paid to GPs working on short-term contracts: low (0–9 %), medium (10–39 %), or high (≥40 %). We used logistic regression to identify determinants of statin treatment.

Results

Among patients with prior CVD, only 34.5 % received statin treatment before myocardial infarction. The probability of statin treatment decreased with age (≥70 years OR 0.30; 95 % CI 0.13–0.66) and female gender (OR 0.39; 95 % CI 0.20–0.78) but increased in patients with diabetes (OR 3.52; 95 % CI 1.75–7.08). Among patients with prior CVD, the type of primary care clinic was not predictive of statin treatment. In the entire study cohort, 17.3 % of patients were treated with statins; women < 70 years old were more likely to receive statin treatment than women ≥70 years old (OR 3.24; 95 % CI 1.64–6.38), and men ≥70 years old were twice as likely to be treated with statins than women of the same age (OR 2.22; 95 % CI 1.31–3.76) after adjusting for diabetes and CVD. Overall, patients from clinics with predominantly permanent staff GPs received statin therapy less frequently than those with GPs on short-term contracts.

Conclusions

In patients with prior CVD we found considerable under-treatment with statins, especially among women and the elderly. Methodologies for case findings, recall, and follow-up need to be improved and implemented to reach the goals for CVD prevention in clinical practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0505-0) contains supplementary material, which is available to authorized users.

Health Outcomes of Population-Based Pharmacy Outreach to Increase Statin Use for Prevention of Cardiovascular Disease in Patients with Diabetes

BACKGROUND

In 2003, Group Health implemented a pharmacy-based, systemwide outreach effort to increase the preventive use of statins and angiotensin-converting enzyme inhibitors in enrollees at risk for cardiovascular disease, including all enrollees with diabetes.

OBJECTIVE

To estimate the associations between the use of statins and major vascular events and the total costs in 2006-2010 for enrollees with diabetes, using a pharmacy-based, systemwide outreach.

METHODS

In a 14-year (1997-2010) longitudinal cohort study design, the study population consisted of 6,975 Group Health enrollees with type 1 or type 2 diabetes, who were enrolled continuously and had no statin use before the Group Health outreach in 1997-2002. Health outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke. Statin exposure was measured by cumulative statin use since 2003, weighted by the effect of the statin type and dose on the lowering of low-density lipoprotein levels. Regression models estimated associations between cumulative statin use, health outcomes, and total costs in 2006-2010.

RESULTS

Among enrollees with no statin use before outreach began in 2003, about half had no or low exposure to statins by the end of 2005. In 2006-2010, cumulative statin use was greater among enrollees with risk factors for cardiovascular disease. Greater statin use was related to lower cardiovascular deaths and incidence of stroke and myocardial infarction, greater but nonsignificant all-cause mortality, and unrelated to total costs.

CONCLUSIONS

Population-based pharmacy outreach increased statin use for eligible enrollees with diabetes, which was related to better cardiovascular outcomes. Generally, statin use was unrelated to all-cause mortality and total costs.

DISCLOSURES

This study was funded by Grant No. R21 HS019501 from the Agency for Healthcare Research and Quality (AHRQ) and was conducted as part of the AHRQ announcement Optimizing Prevention and Healthcare Management for the Complex Patient (R21; RFA-HS-10-009). Ralston and Anderson are employees of Group Health and the Group Health Research Institute, which provided the data for this study. Study concept and design were contributed by Grembowski, Ralston, and Anderson. Anderson assisted with data collection and analysis, and data interpretation was performed by Anderson, along with Grembowski and Ralston. The manuscript was prepared by Grembowski, along with Ralston and Anderson.

Optimal strategies for monitoring lipid levels in patients at risk or with cardiovascular disease: a systematic review with statistical and cost-effectiveness modelling

BACKGROUND

Various lipid measurements in monitoring/screening programmes can be used, alone or in cardiovascular risk scores, to guide treatment for prevention of cardiovascular disease (CVD). Because some changes in lipids are due to variability rather than true change, the value of lipid-monitoring strategies needs evaluation.

OBJECTIVE

To determine clinical value and cost-effectiveness of different monitoring intervals and different lipid measures for primary and secondary prevention of CVD.

DATA SOURCES

We searched databases and clinical trials registers from 2007 (including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Clinical Trials Register, the Current Controlled Trials register, and the Cumulative Index to Nursing and Allied Health Literature) to update and extend previous systematic reviews. Patient-level data from the Clinical Practice Research Datalink and St Luke's Hospital, Japan, were used in statistical modelling. Utilities and health-care costs were drawn from the literature.

METHODS

In two meta-analyses, we used prospective studies to examine associations of lipids with CVD and mortality, and randomised controlled trials to estimate lipid-lowering effects of atorvastatin doses. Patient-level data were used to estimate progression and variability of lipid measurements over time, and hence to model lipid-monitoring strategies. Results are expressed as rates of true-/false-positive and true-/false-negative tests for high lipid or high CVD risk. We estimated incremental costs per quality-adjusted life-year.

RESULTS

A total of 115 publications reported strength of association between different lipid measures and CVD events in 138 data sets. The summary adjusted hazard ratio per standard deviation of total cholesterol (TC) to high-density lipoprotein (HDL) cholesterol ratio was 1.25 (95% confidence interval 1.15 to 1.35) for CVD in a primary prevention population but heterogeneity was high (I(2) = 98%); similar results were observed for non-HDL cholesterol, apolipoprotein B and other ratio measures. Associations were smaller for other single lipid measures. Across 10 trials, low-dose atorvastatin (10 and 20 mg) effects ranged from a TC reduction of 0.92 mmol/l to 2.07 mmol/l, and low-density lipoprotein reduction of between 0.88 mmol/l and 1.86 mmol/l. Effects of 40 mg and 80 mg were reported by one trial each. For primary prevention, over a 3-year period, we estimate annual monitoring would unnecessarily treat 9 per 1000 more men (28 vs. 19 per 1000) and 5 per 1000 more women (17 vs. 12 per 1000) than monitoring every 3 years. However, annual monitoring would also undertreat 9 per 1000 fewer men (7 vs. 16 per 1000) and 4 per 1000 fewer women (7 vs. 11 per 1000) than monitoring at 3-year intervals. For secondary prevention, over a 3-year period, annual monitoring would increase unnecessary treatment changes by 66 per 1000 men and 31 per 1000 women, and decrease undertreatment by 29 per 1000 men and 28 per 1000 men, compared with monitoring every 3 years. In cost-effectiveness, strategies with increased screening/monitoring dominate. Exploratory analyses found that any unknown harms of statins would need utility decrements as large as 0.08 (men) to 0.11 (women) per statin user to reverse this finding in primary prevention.

LIMITATION

Heterogeneity in meta-analyses.

CONCLUSIONS

While acknowledging known and potential unknown harms of statins, we find that more frequent monitoring strategies are cost-effective compared with others. Regular lipid monitoring in those with and without CVD is likely to be beneficial to patients and to the health service. Future research should include trials of the benefits and harms of atorvastatin 40 and 80 mg, large-scale surveillance of statin safety, and investigation of the effect of monitoring on medication adherence.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003727.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Assessment of pharmacogenetic tests: presenting measures of clinical validity and potential population impact in association studies

The progressing discovery of genetic variants associated with drug-related adverse events has raised expectations for pharmacogenetic tests to improve drug efficacy and safety. To further the use of pharmacogenetics in health care, tests with sufficient potential to improve efficacy and safety, as reflected by good clinical validity and population impact, need to be identified. The potential benefit of pharmacogenetic tests is often concluded from the strength of the association between the variant and the adverse event; measures of clinical validity are generally not reported. This paper describes measures of clinical validity and potential population health impact that can be calculated from association studies. We explain how these measures are influenced by the strength of the association and by the frequencies of the variant and the adverse event. The measures are illustrated using examples of testing for HLA-B*5701 associated with abacavir-induced hypersensitivity and SLCO1B1 c.521T>C (*5) associated with simvastatin-induced adverse events.

Statin tolerability: In defence of placebo-controlled trials

BACKGROUND

Statin intolerance is a barrier to effective lipid-lowering treatment. A significant number of patients stop prescribed statins, or can take only a reduced dose, because of adverse events attributed to the statin, and are then considered statin-intolerant.

METHODS

Examination of differences between statin and placebo in withdrawal rates due to adverse events - a good measure of tolerability - in statin cardiovascular outcome trials in patients with advanced disease and complex medical histories, who may be more vulnerable to adverse effects. The arguments commonly used to dismiss safety and tolerability data in statin clinical trials are examined.

RESULTS

Rates of withdrawal due to adverse events in trials in patients with advanced disease and complex medical histories are consistently similar in the statin and placebo groups. We find no support for arguments that statin cardiovascular outcome trials do not translate to clinical practice.

CONCLUSIONS

Given the absence of any signal of intolerance in clinical trials, it appears that statin intolerance in the clinic is commonly due to the nocebo effect causing patients to attribute background symptoms to the statin. Consistent with this, over 90% of patients who have stopped treatment because of an adverse event can tolerate a statin if re-challenged. Consequently, new agents, including monoclonal antibodies to proprotein convertase subtilisin/kexin type 9, will be useful when added to statin therapy but should rarely be used as a statin substitute.

Distribution of lifespan gain from primary prevention intervention

Objective

When advising patients about possible initiation of primary prevention treatment, clinicians currently do not have information on expected impact on lifespan, nor how much this increment differs between individuals.

Methods

First, UK cardiovascular and non-cardiovascular mortality data were used to calculate the mean lifespan gain from an intervention (such as a statin) that reduces cardiovascular mortality by 30%. Second, a new method was developed to calculate the probability distribution of lifespan gain. Third, we performed a survey in three UK cities on 11 days between May–June 2014 involving 396 participants (mean age 40 years, 55% male) to assess how individuals evaluate potential benefit from primary prevention therapies.

Results

Among numerous identical patients, the lifespan gain, from an intervention that reduces cardiovascular mortality by 30%, is concentrated within an unpredictable minority. For example, men aged 50 years with national average cardiovascular risk have mean lifespan gain of 7 months. However, 93% of these identical individuals gain no lifespan, while the remaining 7% gain a mean of 99 months. Many survey respondents preferred a chance of large lifespan gain to the equivalent life expectancy gain given as certainty. Indeed, 33% preferred a 2% probability of 10 years to fivefold more gain, expressed as certainty of 1 year.

Conclusions

People who gain lifespan from preventative therapy gain far more than the average for their risk stratum, even if perfectly defined. This may be important in patient decision-making. Looking beyond mortality reduction alone from preventative therapy, the benefits are likely to be even larger.