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Hobbs FDR, Banach M, Mikhailidis DP, Malhotra A, Capewell S. Is statin-modified reduction in lipids the most important preventive therapy for cardiovascular disease? A pro/con debate. BMC Med 2016; 14:4. [PMID: 26769594 PMCID: PMC4714436 DOI: 10.1186/s12916-016-0550-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 12/01/2015] [Indexed: 12/24/2022] Open
Abstract
The most prescribed medications in the world are statins, lipid modifiers that have been available for over 25 years and amongst the most investigated of all drug classes. With over a million patient years of trial data and publications in the most prestigious medical journals, it is remarkable that quite so much debate remains as to their place in healthcare. They have had a bittersweet passage, with vocal concerns over their possible risks, from suicide to cancer, and allegations that they do not work in women or the elderly, to statements that the whole published dataset, on over 200,000 patients consenting to enter trials, was fatally compromised by being industry-funded by and large. On the other side, there have been billions of dollars spent on generating their evidence base followed by promotion which has returned that investment many times over in profits, and a powerful scientific lobby that argue they are wonder drugs and that continued nihilism on their value risks patient lives. So who is right?
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Affiliation(s)
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland.
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London, London, UK.
| | | | - Simon Capewell
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK.
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102
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Statin Adverse Events in Primary Prevention: Between Randomized Trials and Observational Studies. Am J Med Sci 2015; 350:330-7. [PMID: 26181083 DOI: 10.1097/maj.0000000000000527] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Considerable debate exists regarding who might benefit from statins for primary prevention. Statins have wide pleotropic effects, which contribute to their efficacy in lowering cardiovascular disease but may also result in adverse events (AEs). Caveats in identifying AEs in randomized controlled trials (RCTs) include the lack of a standardized definition of statin-associated AEs, the differences in properties of different statins, the selectivity of RCTs in choosing their participants, the presence of high rate of nonadherence/withdrawal from trials and other concerns related to study design and conflict of interest. Caveats in identifying or overestimating AEs in observational studies include failure to identify baseline confounders, ascertainment bias, confounding by indication and healthy user bias. Statin use in observational studies may be a surrogate marker for higher socioeconomic standards, access to health care or use of other preventive services. Integrating evidence from both RCTs and observational studies is of paramount importance for appropriate patient-centered decision.
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103
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Boulanger-Piette A, Bergeron J, Desgreniers J, Côté-Levesque M, Brassard D, Joanisse DR, Frenette J. [Statin intolerance and associated muscular dysfunctions]. Med Sci (Paris) 2015; 31:1109-14. [PMID: 26672664 DOI: 10.1051/medsci/20153112014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Hypercholesterolemia is a major risk factor for cardiovascular diseases. The 2012-2013 survey of Canada's public health measures revealed that dyslipidemia was present in 38% of the respondents aged between 18 and 79 years. According to the American College of Cardiology, the American Heart Association, the Canadian Cardiovascular Society and the Canadian Working Group Consensus, statins remain the treatment of choice for dyslipidemia and the reduction of cardiovascular risk. However, concerns and questions persist regarding statins use and safety, potential and harmful muscular side-effects, interactions with exercise, and molecular mechanisms of myotoxicity. The goal of the present review is to provide a clear picture of the clinical situation and to investigate possible mechanisms of statin-induced myopathy. A better understanding of muscle pathology in statin users is absolutely essential to minimize their muscle symptoms and to provide a sound clinical basis for the management of cardiovascular risk.
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Affiliation(s)
- Antoine Boulanger-Piette
- Centre de recherche du CHU de Québec-CHUL, université Laval, 2705, boulevard Laurier, Québec, QC, G1V 4G2 Canada
| | - Jean Bergeron
- Centre de recherche du CHU de Québec-CHUL, université Laval, 2705, boulevard Laurier, Québec, QC, G1V 4G2 Canada
| | - Joël Desgreniers
- Faculté de médecine, département de réadaptation, université Laval, 1050, avenue de la Médecine, Québec, QC, G1V 0A6 Canada
| | - Michèle Côté-Levesque
- Faculté de médecine, département de réadaptation, université Laval, 1050, avenue de la Médecine, Québec, QC, G1V 0A6 Canada
| | - Dominic Brassard
- Faculté de médecine, département de réadaptation, université Laval, 1050, avenue de la Médecine, Québec, QC, G1V 0A6 Canada
| | - Denis R Joanisse
- Pavillon éducation physique et sports, université Laval, 2300, rue de la Terrasse, Québec, QC, G1V 0A6, Canada
| | - Jérôme Frenette
- Centre de recherche du CHU de Québec-CHUL, université Laval, 2705, boulevard Laurier, Québec, QC, G1V 4G2 Canada
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104
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Walsh A, Perrem LM, Elshafi M, Khashan AS, Henry M, Ni Chroinin M. Statins versus placebo for people with chronic obstructive pulmonary disease (COPD). Hippokratia 2015. [DOI: 10.1002/14651858.cd011959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Aisling Walsh
- Cork University Hospital; Department of Paediatrics; Cork Ireland
| | - Lucy M Perrem
- Tallaght Hospital (AMNCH); Respiratory; Dublin Ireland
| | - Mohamed Elshafi
- Cork University Hospital; Respiratory Medicine; Cork Ireland
| | - Ali S Khashan
- University College Cork; Irish Centre for Fetal and Neonatal Translational Research (INFANT); 5th Floor, Cork University Maternity Hospital Wilton Cork Munster Ireland
- University College Cork; Department of Epidemiology and Public Health; Cork Ireland
| | - Michael Henry
- Cork University Hospital; Respiratory Medicine; Cork Ireland
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105
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Buettner C, Nir RR, Bertisch SM, Bernstein C, Schain A, Mittleman MA, Burstein R. Simvastatin and vitamin D for migraine prevention: A randomized, controlled trial. Ann Neurol 2015; 78:970-81. [PMID: 26418341 DOI: 10.1002/ana.24534] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 08/21/2015] [Accepted: 09/18/2015] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this work was to assess efficacy and tolerability of simvastatin plus vitamin D for migraine prevention in adults with episodic migraine. METHODS We performed a randomized, double-blind, placebo-controlled trial with a 12-week baseline period and 24-week intervention period in 57 adults with episodic migraine. Participants were randomly assigned to simvastatin 20 mg tablets twice-daily plus vitamin D3 1,000 international units capsules twice-daily or matching placebo tablets and capsules. RESULTS Compared to placebo, participants using simvastatin plus vitamin D3 demonstrated a greater decrease in number of migraine days from the baseline period to intervention weeks 1 to 12: a change of -8.0 (interquartile range [IQR]: -15.0 to -2.0) days in the active treatment group versus +1.0 (IQR: -1.0 to + 6.0) days in the placebo group, p < 0.001; and to intervention weeks 13 to 24: a change of -9.0 (IQR: -13 to -5) days in the active group versus +3.0 (IQR: -1.0 to + 5.0) days in the placebo group, p < 0.001. In the active treatment group, 8 patients (25%) experienced 50% reduction in the number of migraine days at 12 weeks and 9 (29%) at 24 weeks postrandomization. In comparison, only 1 patient (3%) in the placebo group (p = 0.03) experienced such a reduction. Adverse events were similar in both active treatment and placebo groups. INTERPRETATION The results demonstrate that simvastatin plus vitamin D is effective for prevention of headache in adults with episodic migraine. Given statins' ability to repair endothelial dysfunction, this economical approach may also reduce the increased risk for vascular diseases among migraineurs.
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Affiliation(s)
- Catherine Buettner
- Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Rony-Reuven Nir
- Department of Neurology, Rambam Health Care Campus, and Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Suzanne M Bertisch
- Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Carolyn Bernstein
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Aaron Schain
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Murray A Mittleman
- Department of Epidemiology, Harvard School of Public Health, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Rami Burstein
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
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106
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Mühlbauer V, Mühlhauser I. Understanding adverse drug reactions in package leaflets - an exploratory survey among health care professionals. BMC Health Serv Res 2015; 15:505. [PMID: 26554666 PMCID: PMC4641349 DOI: 10.1186/s12913-015-1160-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 10/30/2015] [Indexed: 01/22/2023] Open
Abstract
Background Current German or UK package leaflets do not contain an explicit notice that the listing of side effects does not imply that they are caused by the drug. Causal interpretations by patients and lay people are frequently observed. The authors examined whether health professionals understand that there is not necessarily a causal relation between drug intake and the frequency of side effects and whether adding placebo comparison improves understanding. Methods Exploratory survey consisting of eight assessments, each containing 2–6 survey items, and focus groups with one survey sample using questionnaires on adverse reactions in standard package leaflets and modified package leaflets supplemented with placebo comparison. Participants were convenience samples of 379 health professionals including 153 physicians (80 gynaecologists, 124 diabetes experts - physicians, nurses, and others, 39 medical students in their last year at university, 49 first year health science and education students with completed vocational training and professional experience in various health care professions and 87 pharmacists/pharmacy students). They were asked to rate how often the different adverse reactions listed were caused by drug intake. All surveys were carried out within university seminars and postgraduate lectures from April 2014 to June 2015 in Germany. Response rate was 86 % or higher. Results Without placebo comparison, the majority of participants responded that the drug causes adverse reactions with the frequency given in the package leaflet or even more often (95 % of health science students, 100 % of medical students, 60 to 80 % of physicians and 66 % of pharmacists/pharmacy students). Simply adding placebo comparison in a table did not prevent misunderstanding. Analysis of focus groups with health science students supported the lack of understanding. Conclusions In the present surveys, health professionals had major difficulties understanding frequency information on side effects in package leaflets. The great majority erroneously implied a causal relation between drug intake and the frequency of side effects, even though most side effects listed are symptoms commonly experienced in daily life. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1160-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Viktoria Mühlbauer
- University of Hamburg, MIN Faculty, Health Sciences and Education, Martin-Luther-King Platz 6, D-20146, Hamburg, Germany.
| | - Ingrid Mühlhauser
- University of Hamburg, MIN Faculty, Health Sciences and Education, Martin-Luther-King Platz 6, D-20146, Hamburg, Germany.
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107
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Hammami R, Jdidi J, Triki F, Hammami B, Abid L, Ksouda K, Hammami S, Abid D, Hentati M, Kammoun S. [Statins Use in Elderly Patients]. Therapie 2015; 78:therapie150057. [PMID: 26524698 DOI: 10.2515/therapie/2015057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 04/16/2015] [Indexed: 02/28/2024]
Abstract
The risk of cardiovascular disease in elderly is significantly higher than in young subjects; paradoxically some treatments that have proven their efficacy in reducing cardiovascular risk are often under prescribed in this age group. The benefits of statins in secondary cardiovascular prevention are well established in patients <80 years. In primary prevention, these drugs reduce the risk of myocardial infarction and stroke, but their effects on cardiovascular mortality remain uncertain. In very elderly patients, there are no randomized trials relative to the impact of statins on morbi-mortality in primary prevention as well in secondary prevention. Adverse effects in the elderly seem to be statistically similar to those occurring in young people , but the prescription in very old people should be individualized, taking into account the life expectancy, the life quality, the comorbidities, and especially the risk of drug interactions.
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Affiliation(s)
- Rania Hammami
- Service de Cardiologie de Sfax, CHU Hedi Chaker, Sfax, Tunisie
| | - Jihen Jdidi
- Service de Médecine Préventive, CHU Hedi Chaker, Sfax, Tunisie
| | - Faten Triki
- Service de Cardiologie de Sfax, CHU Hedi Chaker, Sfax, Tunisie
| | | | - Leila Abid
- Service de Cardiologie de Sfax, CHU Hedi Chaker, Sfax, Tunisie
| | - Kamilia Ksouda
- Laboratoire de Pharmacologie, Faculté de Médecine, Sfax, Tunisie
| | - Serria Hammami
- Laboratoire de Pharmacologie, Faculté de Médecine, Sfax, Tunisie
| | - Dorra Abid
- Service de Cardiologie de Sfax, CHU Hedi Chaker, Sfax, Tunisie
| | - Mourad Hentati
- Service de Cardiologie de Sfax, CHU Hedi Chaker, Sfax, Tunisie
| | - Samir Kammoun
- Service de Cardiologie de Sfax, CHU Hedi Chaker, Sfax, Tunisie
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108
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Sundsted KK, Wieland ML, Szostek JH, Post JA, Mauck KF. Update in outpatient general internal medicine: practice-changing evidence published in 2014. Am J Med 2015; 128:1065-9. [PMID: 26052025 DOI: 10.1016/j.amjmed.2015.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 04/13/2015] [Accepted: 04/13/2015] [Indexed: 11/17/2022]
Abstract
The practice of outpatient general internal medicine requires a diverse and evolving knowledge base. General internists must identify practice-changing shifts in the literature and reflect on their impact. Accordingly, we conducted a review of practice-changing articles published in outpatient general internal medicine in 2014. To identify high-quality, clinically relevant publications, we reviewed all titles and abstracts published in the following primary data sources in 2014: New England Journal of Medicine, Journal of the American Medical Association (JAMA), Annals of Internal Medicine, JAMA Internal Medicine, and the Cochrane Database of Systematic Reviews. All 2014 primary data summaries from Journal Watch-General Internal Medicine and ACP JournalWise also were reviewed. The authors used a modified Delphi method to reach consensus on inclusion of 8 articles using the following criteria: clinical relevance to outpatient internal medicine, potential for practice change, and strength of evidence. Clusters of important articles around one clinical question were considered as a single-candidate series. The article merits were debated until consensus was reached on the final 8, spanning a variety of topics commonly encountered in outpatient general internal medicine.
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Affiliation(s)
- Karna K Sundsted
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn.
| | - Mark L Wieland
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn
| | - Jason H Szostek
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn
| | - Jason A Post
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn
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109
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Strategies for Primary Prevention of Coronary Heart Disease Based on Risk Stratification by the ACC/AHA Lipid Guidelines, ATP III Guidelines, Coronary Calcium Scoring, and C-Reactive Protein, and a Global Treat-All Strategy: A Comparative--Effectiveness Modeling Study. PLoS One 2015; 10:e0138092. [PMID: 26422204 PMCID: PMC4589241 DOI: 10.1371/journal.pone.0138092] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 08/26/2015] [Indexed: 02/07/2023] Open
Abstract
Background Several approaches have been proposed for risk-stratification and primary prevention of coronary heart disease (CHD), but their comparative and cost-effectiveness is unknown. Methods We constructed a state-transition microsimulation model to compare multiple approaches to the primary prevention of CHD in a simulated cohort of men aged 45–75 and women 55–75. Risk-stratification strategies included the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of blood cholesterol, the Adult Treatment Panel (ATP) III guidelines, and approaches based on coronary artery calcium (CAC) scoring and C-reactive protein (CRP). Additionally we assessed a treat-all strategy in which all individuals were prescribed either moderate-dose or high-dose statins and all males received low-dose aspirin. Outcome measures included CHD events, costs, medication-related side effects, radiation-attributable cancers, and quality-adjusted-life-years (QALYs) over a 30-year timeframe. Results Treat-all with high-dose statins dominated all other strategies for both men and women, gaining 15.7 million QALYs, preventing 7.3 million myocardial infarctions, and saving over $238 billion, compared to the status quo, far outweighing its associated adverse events including bleeding, hepatitis, myopathy, and new-onset diabetes. ACC/AHA guidelines were more cost-effective than ATP III guidelines for both men and women despite placing 8.7 million more people on statins. For women at low CHD risk, treat-all with high-dose statins was more likely to cause a statin-related adverse event than to prevent a CHD event. Conclusions Despite leading to a greater proportion of the population placed on statin therapy, the ACC/AHA guidelines are more cost-effective than ATP III. Even so, at generic prices, treating all men and women with statins and all men with low-dose aspirin appears to be more cost-effective than all risk-stratification approaches for the primary prevention of CHD. Especially for low-CHD risk women, decisions on the appropriate primary prevention strategy should be based on shared decision making between patients and healthcare providers.
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110
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Stock J. Statin-associated muscle symptoms EAS Consensus Panel paper focuses on this neglected patient group. Atherosclerosis 2015; 242:346-50. [DOI: 10.1016/j.atherosclerosis.2015.06.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 06/25/2015] [Indexed: 11/28/2022]
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111
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Baldi B, Utts J. What Your Future Doctor Should Know About Statistics: Must-Include Topics for Introductory Undergraduate Biostatistics. AM STAT 2015. [DOI: 10.1080/00031305.2015.1048903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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112
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Downs JR, O'Malley PG. Management of dyslipidemia for cardiovascular disease risk reduction: synopsis of the 2014 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline. Ann Intern Med 2015; 163:291-7. [PMID: 26099117 DOI: 10.7326/m15-0840] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION In December 2014, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the management of dyslipidemia for cardiovascular disease risk reduction in adults. This synopsis summarizes the major recommendations. METHODS On 30 September 2013, the VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, developed a simple 1-page algorithm, and rated each of 26 recommendations by using the Grading of Recommendations Assessment, Development, and Evaluation system. RECOMMENDATIONS This synopsis summarizes key features of the guideline in 5 areas: elimination of treatment targets, additional tests for risk prediction, primary and secondary prevention, and laboratory testing.
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Affiliation(s)
- John R. Downs
- From South Texas Veterans Health Care System, San Antonio, Texas, and Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Patrick G. O'Malley
- From South Texas Veterans Health Care System, San Antonio, Texas, and Uniformed Services University of the Health Sciences, Bethesda, Maryland
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113
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Duerden M, O'Flynn N, Qureshi N. Cardiovascular risk assessment and lipid modification: NICE guideline. Br J Gen Pract 2015; 65:378-80. [PMID: 26120133 PMCID: PMC4484941 DOI: 10.3399/bjgp15x685933] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 12/15/2014] [Indexed: 10/31/2022] Open
Affiliation(s)
- Martin Duerden
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor
| | - Norma O'Flynn
- National Clinical Guideline Centre for Acute and Chronic Conditions, Royal College of Physicians, London
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114
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Liakopoulos OJ, Kuhn EW, Hellmich M, Kuhr K, Krause P, Reuter H, Thurat M, Choi YH, Wahlers T. Statin Recapture Therapy before Coronary Artery Bypass Grafting Trial: Rationale and study design of a multicenter, randomized, double-blinded controlled clinical trial. Am Heart J 2015; 170:46-54, 54.e1-2. [PMID: 26093863 DOI: 10.1016/j.ahj.2015.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 04/15/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Patients undergoing coronary artery bypass grafting (CABG) are still at significant risk for postoperative major adverse cardiac and cerebrovascular events (MACCEs). Recent clinical evidence shows that cardioprotection in patients receiving a chronic statin treatment can be "recaptured" by a high-dose statin therapy given shortly before an ischemia-reperfusion sequence. Evaluation of this novel therapeutic approach in the setting of CABG seems promising because myocardial ischemia-reperfusion injury plays a pivotal role in poor clinical outcomes that may be improved by a simple preoperative statin recapture treatment. METHODS The investigator-initiated StaRT-CABG trial is a multicenter, randomized, double-blinded, 2-parallel group controlled clinical study in 2,630 patients. The trial aims to evaluate whether a high-dose statin recapture therapy given shortly before CABG reduces the incidence of MACCE at 30 days after surgery (primary composite outcome: all-cause mortality, nonfatal myocardial infarction, and cerebrovascular events). Consenting patients who are on chronic statin therapy before surgery will be randomized to receive either oral statin reloading therapy or matching placebo 12 and 2 hours before CABG. Key secondary end points include enzymatic myocardial injury; new-onset atrial fibrillation; length of stay in the intensive care unit and hospital; need for repeat coronary revascularization at 30 days; and, finally, all-cause mortality at 12 months after surgery. IMPLICATIONS The StaRT-CABG trial is expected to provide highly relevant clinical data on the efficacy of this novel therapeutic approach to optimize the care for patients with coronary artery disease undergoing CABG.
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115
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Khalil D, Boktor M, Mortensen EM, Frei CR, Mansi I. Comparison of frequency of inflammatory bowel disease and noninfectious gastroenteritis among statin users versus nonusers. Am J Cardiol 2015; 115:1396-401. [PMID: 25784517 DOI: 10.1016/j.amjcard.2015.02.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 02/06/2015] [Accepted: 02/06/2015] [Indexed: 12/18/2022]
Abstract
Conflicting data exist regarding the effects of statin therapy on the prevalence of inflammatory bowel diseases. We aimed to examine the association of statin therapy with diagnoses of inflammatory bowel diseases and noninfectious gastroenteritis. This is a retrospective study using data of a military health care system from October 1, 2003, to March 1, 2012. Based on medication fills during fiscal year 2005, patients were divided into: (1) statin users (received at least 90-day supply of statin) and (2) nonusers (never received a statin). A propensity score-matched cohort of statin users and nonusers was created using 80 variables. Primary analysis examined the risks of being diagnosed with inflammatory bowel diseases and noninfectious gastroenteritis between statin users and nonusers in the propensity score-matched cohort. Secondary analyses examined the risk of outcomes in the whole cohort and in patients with no comorbidities according to Charlson Comorbidity Index. Of 43,438 patients meeting study criteria (13,626 statin users and 29,812 nonusers), we propensity score matched 6,342 statin users with 6,342 nonusers. For our primary analysis, 93 statin users and 92 nonusers were diagnosed with inflammatory bowel diseases (odds ratio = 1.01, 95% confidence interval = 0.76 to 1.35), and 632 statin users and 619 nonusers were diagnosed of noninfectious gastroenteritis (odds ratio = 1.02, 95% confidence interval = 0.91 to 1.15). In conclusion, the risks of inflammatory bowel diseases and noninfectious gastroenteritis among statin users and nonusers are similar after adjusting for other potential confounding factors.
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116
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Stroes ES, Thompson PD, Corsini A, Vladutiu GD, Raal FJ, Ray KK, Roden M, Stein E, Tokgözoğlu L, Nordestgaard BG, Bruckert E, De Backer G, Krauss RM, Laufs U, Santos RD, Hegele RA, Hovingh GK, Leiter LA, Mach F, März W, Newman CB, Wiklund O, Jacobson TA, Catapano AL, Chapman MJ, Ginsberg HN. Statin-associated muscle symptoms: impact on statin therapy-European Atherosclerosis Society Consensus Panel Statement on Assessment, Aetiology and Management. Eur Heart J 2015; 36:1012-22. [PMID: 25694464 PMCID: PMC4416140 DOI: 10.1093/eurheartj/ehv043] [Citation(s) in RCA: 886] [Impact Index Per Article: 98.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 01/22/2015] [Accepted: 01/26/2015] [Indexed: 12/14/2022] Open
Abstract
Statin-associated muscle symptoms (SAMS) are one of the principal reasons for statin non-adherence and/or discontinuation, contributing to adverse cardiovascular outcomes. This European Atherosclerosis Society (EAS) Consensus Panel overviews current understanding of the pathophysiology of statin-associated myopathy, and provides guidance for diagnosis and management of SAMS. Statin-associated myopathy, with significant elevation of serum creatine kinase (CK), is a rare but serious side effect of statins, affecting 1 per 1000 to 1 per 10 000 people on standard statin doses. Statin-associated muscle symptoms cover a broader range of clinical presentations, usually with normal or minimally elevated CK levels, with a prevalence of 7-29% in registries and observational studies. Preclinical studies show that statins decrease mitochondrial function, attenuate energy production, and alter muscle protein degradation, thereby providing a potential link between statins and muscle symptoms; controlled mechanistic and genetic studies in humans are necessary to further understanding. The Panel proposes to identify SAMS by symptoms typical of statin myalgia (i.e. muscle pain or aching) and their temporal association with discontinuation and response to repetitive statin re-challenge. In people with SAMS, the Panel recommends the use of a maximally tolerated statin dose combined with non-statin lipid-lowering therapies to attain recommended low-density lipoprotein cholesterol targets. The Panel recommends a structured work-up to identify individuals with clinically relevant SAMS generally to at least three different statins, so that they can be offered therapeutic regimens to satisfactorily address their cardiovascular risk. Further research into the underlying pathophysiological mechanisms may offer future therapeutic potential.
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Affiliation(s)
- Erik S Stroes
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | - Georgirene D Vladutiu
- School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | | | | | - Michael Roden
- Department of Endocrinology and Diabetology, University Hospital Düsseldorf Heinrich-Heine University, and Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Germany
| | - Evan Stein
- Metabolic and Atherosclerosis Research Centre, Cincinnati, OH, USA
| | | | - Børge G Nordestgaard
- Herlev Hospital, Copenhagen University Hospital, University of Copenhagen, Denmark
| | - Eric Bruckert
- Pitié-Salpetriere University Hospital, Paris, France
| | | | - Ronald M Krauss
- Children's Hospital Oakland Research Institute, Oakland, CA, USA
| | - Ulrich Laufs
- Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | | | | | - G Kees Hovingh
- Academic Medical Center, University of Amsterdam, The Netherlands
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute and Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Canada
| | | | - Winfried März
- Synlab Center of Laboratory Diagnostics Heidelberg, Heidelberg, Germany
| | | | - Olov Wiklund
- Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - M John Chapman
- INSERM, Pitié-Salpetriere University Hospital, Paris, France
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117
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Banach M, Rizzo M, Toth PP, Farnier M, Davidson MH, Al-Rasadi K, Aronow WS, Athyros V, Djuric DM, Ezhov MV, Greenfield RS, Hovingh GK, Kostner K, Serban C, Lighezan D, Fras Z, Moriarty PM, Muntner P, Goudev A, Ceska R, Nicholls SJ, Broncel M, Nikolic D, Pella D, Puri R, Rysz J, Wong ND, Bajnok L, Jones SR, Ray KK, Mikhailidis DP. Statin intolerance – an attempt at a unified definition. Position paper from an International Lipid Expert Panel. Expert Opin Drug Saf 2015; 14:935-55. [PMID: 25907232 DOI: 10.1517/14740338.2015.1039980] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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118
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Faasse K, Grey A, Horne R, Petrie KJ. High perceived sensitivity to medicines is associated with higher medical care utilisation, increased symptom reporting and greater information-seeking about medication. Pharmacoepidemiol Drug Saf 2015; 24:592-9. [DOI: 10.1002/pds.3751] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 12/11/2014] [Accepted: 12/13/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Kate Faasse
- Department of Psychological Medicine and Department of Medicine; The University of Auckland; Auckland New Zealand
- UCL School of Pharmacy; London UK
| | - Andrew Grey
- Department of Psychological Medicine and Department of Medicine; The University of Auckland; Auckland New Zealand
- UCL School of Pharmacy; London UK
| | - Rob Horne
- Department of Psychological Medicine and Department of Medicine; The University of Auckland; Auckland New Zealand
- UCL School of Pharmacy; London UK
| | - Keith J. Petrie
- Department of Psychological Medicine and Department of Medicine; The University of Auckland; Auckland New Zealand
- UCL School of Pharmacy; London UK
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119
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Banach M, Rizzo M, Toth PP, Farnier M, Davidson MH, Al-Rasadi K, Aronow WS, Athyros V, Djuric DM, Ezhov MV, Greenfield RS, Hovingh GK, Kostner K, Serban C, Lighezan D, Fras Z, Moriarty PM, Muntner P, Goudev A, Ceska R, Nicholls SJ, Broncel M, Nikolic D, Pella D, Puri R, Rysz J, Wong ND, Bajnok L, Jones SR, Ray KK, Mikhailidis DP. Statin intolerance - an attempt at a unified definition. Position paper from an International Lipid Expert Panel. Arch Med Sci 2015; 11:1-23. [PMID: 25861286 PMCID: PMC4379380 DOI: 10.5114/aoms.2015.49807] [Citation(s) in RCA: 276] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 03/08/2015] [Accepted: 03/10/2015] [Indexed: 02/07/2023] Open
Abstract
Statins are one of the most commonly prescribed drugs in clinical practice. They are usually well tolerated and effectively prevent cardiovascular events. Most adverse effects associated with statin therapy are muscle-related. The recent statement of the European Atherosclerosis Society (EAS) has focused on statin associated muscle symptoms (SAMS), and avoided the use of the term 'statin intolerance'. Although muscle syndromes are the most common adverse effects observed after statin therapy, excluding other side effects might underestimate the number of patients with statin intolerance, which might be observed in 10-15% of patients. In clinical practice, statin intolerance limits effective treatment of patients at risk of, or with, cardiovascular disease. Knowledge of the most common adverse effects of statin therapy that might cause statin intolerance and the clear definition of this phenomenon is crucial to effectively treat patients with lipid disorders. Therefore, the aim of this position paper was to suggest a unified definition of statin intolerance, and to complement the recent EAS statement on SAMS, where the pathophysiology, diagnosis and the management were comprehensively presented.
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Affiliation(s)
- Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland
| | - Manfredi Rizzo
- Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Peter P. Toth
- University of Illinois College of Medicine, Peoria, IL, USA
| | | | | | | | - Wilbert S. Aronow
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
| | - Vasilis Athyros
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Dragan M. Djuric
- Institute of Medical Physiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marat V. Ezhov
- Department of Atherosclerosis, Cardiology Research Center, Moscow, Russia
| | | | - G. Kees Hovingh
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Karam Kostner
- Mater Hospital, University of Queensland, St Lucia, QLD, Australia
| | - Corina Serban
- University of Medicine and Pharmacy “Victor Babes” Timisoara, Romania
| | - Daniel Lighezan
- University of Medicine and Pharmacy “Victor Babes” Timisoara, Romania
| | - Zlatko Fras
- Department of Vascular Medicine, Preventive Cardiology Unit, University Medical Centre Ljubljana, Slovenia Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Patrick M. Moriarty
- Department of Medicine, Schools of Pharmacy and Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Assen Goudev
- Department of Cardiology, Queen Giovanna University Hospital, Sofia, Bulgaria
| | - Richard Ceska
- 3 Department of Internal Medicine, Charles University, Praha, Czech Republic
| | - Stephen J. Nicholls
- South Australian Health and Medical Research Institute and University of Adelaide, Adelaide, Australia
| | - Marlena Broncel
- Department of Internal Medicine and Clinical Pharmacology, Medical University of Lodz, Poland
| | - Dragana Nikolic
- Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Daniel Pella
- First Department Of Internal Medicine, Pavol Jozef Safarik University and Louis Pasteur University Hospital, Košice, Slovakia
| | | | - Jacek Rysz
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland
| | - Nathan D. Wong
- Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine, Irvine, CA, USA
| | - Laszlo Bajnok
- First Department of Medicine, University of Pecs, Pecs, Hungary
| | - Steven R. Jones
- The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Kausik K. Ray
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry, Royal Free Campus, University College London Medical School, University College London (UCL), London, UK
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120
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Statins and voriconazole induce programmed cell death in Acanthamoeba castellanii. Antimicrob Agents Chemother 2015; 59:2817-24. [PMID: 25733513 DOI: 10.1128/aac.00066-15] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 02/25/2015] [Indexed: 12/11/2022] Open
Abstract
Members of the genus Acanthamoeba are facultative pathogens of humans, causing a sight-threatening keratitis and a life-threatening encephalitis. In order to treat those infections properly, it is necessary to target the treatment not only to the trophozoite but also to the cyst. Furthermore, it may be advantageous to avoid parasite killing by necrosis, which may induce local inflammation. We must also avoid toxicity of host tissue. Many drugs which target eukaryotes are known to induce programmed cell death (PCD), but this process is poorly characterized in Acanthamoeba. Here, we study the processes of programmed cell death in Acanthamoeba, induced by several drugs, such as statins and voriconazole. We tested atorvastatin, fluvastatin, simvastatin, and voriconazole at the 50% inhibitory concentrations (IC50s) and IC90s that we have previously established. In order to evaluate this phenomenon, we investigated the DNA fragmentation, one of the main characteristics of PCD, with quantitative and qualitative techniques. Also, the changes related to phosphatidylserine exposure on the external cell membrane and cell permeability were studied. Finally, because caspases are key to PCD pathways, caspase activity was evaluated in Acanthamoeba. All the drugs assayed in this study induced PCD in Acanthamoeba. To the best of our knowledge, this is the first study where PCD induced by drugs is described quantitatively and qualitatively in Acanthamoeba.
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121
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Seguí Díaz M, Divisón J, Escobar Cervantes C. ¿Modifica la ingesta calórica y el consumo de grasas la utilización de estatinas? Semergen 2015; 41:108-9. [DOI: 10.1016/j.semerg.2014.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Accepted: 08/13/2014] [Indexed: 10/24/2022]
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122
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Sullivan DR, Watts GF, Nicholls SJ, Barter P, Grenfell R, Chow CK, Tonkin A, Keech A. Clinical guidelines on hyperlipidaemia: recent developments, future challenges and the need for an Australian review. Heart Lung Circ 2015; 24:495-502. [PMID: 25676115 DOI: 10.1016/j.hlc.2014.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 12/03/2014] [Accepted: 12/08/2014] [Indexed: 12/11/2022]
Abstract
Large reductions in cardiovascular disease (CVD) mortality have been achieved over the last 50 years in developed countries. The health policies that have contributed so much to this success have largely been coordinated by means of expert guidelines for the management of the classic modifiable risk factors such as blood pressure, diabetes and blood lipids. National and international guidelines for lipid management have demonstrated a high degree of consistency between numerous sets of recommendations. It has been argued that some important components of the consensus that has been established over the past decade have been challenged by the latest guidelines of the American Heart Association - American College of Cardiologists (AHA-ACC). Clinicians can be reassured that continued reliance on extensive scientific evidence has reaffirmed the importance of lipid metabolism as a modifiable risk factor for atherosclerotic cardiovascular disease. On the other hand, the recent AHA-ACC guidelines suggest changes in the strategies by which metabolic risk factors may be modified. This small number of important changes should not be sensationalised because these differences usefully reflect the need for guidelines to evolve to accommodate different contexts and changing perspectives as well as emerging issues and new information for which clinical trial evidence is incomplete. This article will consider the recent policies and responses of national and supranational organisations on topics including components of CVD risk assessment, sources of CVD risk information and re-appraisal of lipid-lowering interventions. Timely review of Australian lipid management guidelines will require consideration of these issues because they are creating a new context within which new guidelines must evolve.
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Affiliation(s)
- D R Sullivan
- Department of Chemical Pathology, Royal Prince Alfred Hospital, Camperdown, NSW.
| | - G F Watts
- Department of Medicine, University of Western Australia, Perth, WA
| | - S J Nicholls
- South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, SA
| | - P Barter
- Centre for Vascular Research, University of NSW, Sydney NSW
| | - R Grenfell
- National Heart Foundation Director of Cardiovascular Health, Melbourne Vic
| | - C K Chow
- The George Institute for International Health, University of Sydney, Camperdown, Sydney NSW
| | - A Tonkin
- Cardiovascular Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic
| | - A Keech
- NHMRC Clinical Trials Centre, University of Sydney and Royal Prince Alfred Hospital, University of Sydney, NSW
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123
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Affiliation(s)
- David Preiss
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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124
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Cole GD, Shun-Shin MJ, Finegold JA, Nowbar AN, Francis DP. Grateful receipt of clarifications on a perioperative trial: an illustration of the duty of readers to ask questions. Int J Cardiol 2015; 179:507-9. [PMID: 25465819 DOI: 10.1016/j.ijcard.2014.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 11/04/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Graham D Cole
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK.
| | - Matthew J Shun-Shin
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Judith A Finegold
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Alexandra N Nowbar
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA, UK
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125
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Müller-Wieland D, Assmann G, Carmena R, Davignon J, von Eckardstein A, Farinaro E, Greten H, Olsson AG, Riesen WF, Shlyakhto E. Treat-to-target versus dose-adapted statin treatment of cholesterol to reduce cardiovascular risk. Eur J Prev Cardiol 2015; 23:275-81. [PMID: 25595550 DOI: 10.1177/2047487314567001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/13/2014] [Indexed: 11/17/2022]
Abstract
Clinical guidelines should be based on the best available evidence and are of great importance for patient care and disease prevention. In this respect, the 2013 American College of Cardiology/American Heart Association report is highly appreciated and well-recognized. The report included critical questions concerning hypercholesterolaemia, but its translation into a clinical guideline initiated intense debate worldwide because of the recommendation to switch from a treat-to-target approach for low-density-lipoprotein-cholesterol to a statin dose-based strategy.
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Affiliation(s)
- Dirk Müller-Wieland
- Department of General Internal Medicine, Head, Endocrinology, Diabetes and Metabolism, Asklepios Clinic St Georg, Hamburg, Germany
| | - Gerd Assmann
- Assmann-Foundation for Prevention, Münster, Germany
| | - Rafael Carmena
- Universitat de València and Director-General of Fundación INCLIVA, Valencia, Spain
| | - Jean Davignon
- Institut de recherches cliniques de Montréal (IRCM), Faculty of Medicine at the Université de Montréal, Canada
| | | | - Eduardo Farinaro
- Department Public Health, Medical School University of Naples Federico II, Italy
| | - Heiner Greten
- Hanseatic Heart Centre, Asklepios Clinic St Georg, Hamburg, Germany
| | - Anders G Olsson
- Department of Medicine and Health, Faculty of Health Sciences, University of Linköping and Stockholm Heart Centre, Sweden
| | | | - Evgenyi Shlyakhto
- Almazov Research Institute of Cardiology, Russian Federation Agency of Health and Social Development, Saint Petersburg, Russia
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126
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Aarnio E, Korhonen MJ, Huupponen R, Martikainen J. Cost-effectiveness of statin treatment for primary prevention in conditions of real-world adherence--estimates from the Finnish prescription register. Atherosclerosis 2015; 239:240-7. [PMID: 25618032 DOI: 10.1016/j.atherosclerosis.2014.12.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/18/2014] [Accepted: 12/24/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To estimate the cost-effectiveness of statin therapy for primary prevention of coronary heart disease (CHD) events under real-world adherence. METHODS A cost-effectiveness model was applied to estimate the expected 10-year costs and health outcomes (in terms of quality-adjusted life-years, QALYs) associated with and without statin treatment (at defined adherence levels) among hypothetical cohorts of Finnish men and women who were initially without established CHD. Treatment efficacy, cost, and quality of life estimates were obtained from published sources. Long-term treatment adherence was measured based on data from the national prescription register. RESULTS At an assumed willingness-to-pay threshold of €20,000 per QALY gained, statin treatment with real-world adherence was cost-effective among the older patient groups when the patients' 10-year CHD risk was as high as 20% and did not seem cost-effective in the youngest age groups. Conversely, statin treatment with full adherence was cost-effective for almost all patient groups with a 10-year CHD risk of at least 15%. CONCLUSIONS Even though generic statins are now low-cost drugs, treatment adherence seems to have a major impact on the cost-effectiveness of statin treatment in primary prevention. This finding stresses the importance of making a concerted effort for improving adherence among patients on statin therapy to obtain full benefit of the investment in statins. Therefore, novel cost-effective approaches to improve treatment adherence are warranted.
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Affiliation(s)
- Emma Aarnio
- Department of Clinical Pharmacology, Tykslab, Turku University Hospital, Turku, Finland; Pharmacoeconomics and Outcomes Research Unit (PHORU), School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
| | - Maarit J Korhonen
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland.
| | - Risto Huupponen
- Department of Clinical Pharmacology, Tykslab, Turku University Hospital, Turku, Finland; Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland.
| | - Janne Martikainen
- Pharmacoeconomics and Outcomes Research Unit (PHORU), School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
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127
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Affiliation(s)
- G De Backer
- Department Public Health, Ghent University, Ghent, Belgium
| | - J J P Kastelein
- Department Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - U Landmesser
- Department Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany
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128
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McFadden E, Stevens R, Glasziou P, Perera R. Implications of lower risk thresholds for statin treatment in primary prevention: analysis of CPRD and simulation modelling of annual cholesterol monitoring. Prev Med 2015; 70:14-6. [PMID: 25445333 PMCID: PMC4295934 DOI: 10.1016/j.ypmed.2014.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 11/03/2014] [Accepted: 11/10/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To estimate numbers affected by a recent change in UK guidelines for statin use in primary prevention of cardiovascular disease. METHOD We modelled cholesterol ratio over time using a sample of 45,151 men (≥40years) and 36,168 women (≥55years) in 2006, without statin treatment or previous cardiovascular disease, from the Clinical Practice Research Datalink. Using simulation methods, we estimated numbers indicated for new statin treatment, if cholesterol was measured annually and used in the QRISK2 CVD risk calculator, using the previous 20% and newly recommended 10% thresholds. RESULTS We estimate that 58% of men and 55% of women would be indicated for treatment by five years and 71% of men and 73% of women by ten years using the 20% threshold. Using the proposed threshold of 10%, 84% of men and 90% of women would be indicated for treatment by 5years and 92% of men and 98% of women by ten years. CONCLUSION The proposed change of risk threshold from 20% to 10% would result in the substantial majority of those recommended for cholesterol testing being indicated for statin treatment. Implications depend on the value of statins in those at low to medium risk, and whether there are harms.
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Affiliation(s)
- Emily McFadden
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK.
| | - Richard Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK.
| | - Paul Glasziou
- Faculty of Health Sciences and Medicine, Bond University, Queensland 4229, Australia.
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK.
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129
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Abstract
PURPOSE OF REVIEW To examine the current evidence concerning the effects of genetic variation on statin-related low-density lipoprotein cholesterol reductions, clinical efficacy, and adverse events and the relevance for patient care. RECENT FINDINGS Recent years have seen the emergence of large-scale genetic experiments, including genome-wide association studies and candidate gene studies, exploring the impact of common genetic variation on patient response to statins. These studies have built on previous smaller scale evidence, providing improved statistical power and enhanced ability to explore the genome. Current evidence suggests that common genetic variants do not alter low-density lipoprotein cholesterol response by more than a few percent, or materially alter the effect of statin on vascular risk reduction, and therefore that patients benefit from statins independent of common genetic variation. However, knowledge of SLCO1B1 genotypes is believed to have clinical utility for predicting myopathy risk and ensuring that statins are prescribed as safely as possible. Furthermore, new hypothesis-generating studies, such as those associating GATM with myopathy risk, offer potential insights for the future. SUMMARY Common genetic variation does not appear to be an important determinant of statin response, with the exception of SLCO1B1 and risk of myopathy. Future studies will help to determine the impact of low-frequency and rare genetic variation on statin response.
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Affiliation(s)
- Jemma C Hopewell
- CTSU, Nuffield Department of Population Health, University of Oxford, Oxford, UK *Jemma C. Hopewell, Christina Reith and Jane Armitage contributed equally to the writing of this article
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130
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Thompson PL, Thompson AG, Judkins C. Optimising pharmacotherapy for secondary prevention of non‐invasively managed acute coronary syndrome. Med J Aust 2014; 201:S100-5. [DOI: 10.5694/mja14.01155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 10/15/2014] [Indexed: 01/22/2023]
Affiliation(s)
- Peter L Thompson
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA
- Sir Charles Gairdner Hospital, Perth, WA
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131
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Finegold JA, Francis DP. What proportion of symptomatic side-effects in patients taking statins are genuinely caused by the drug? A response to letters. Eur J Prev Cardiol 2014; 22:1328-30. [DOI: 10.1177/2047487314550805] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Judith A Finegold
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, UK
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132
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Auer J, Sinzinger H, Franklin B, Berent R. Muscle- and skeletal-related side-effects of statins: tip of the iceberg? Eur J Prev Cardiol 2014; 23:88-110. [DOI: 10.1177/2047487314550804] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 08/18/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Johann Auer
- Department of Cardiology and Intensive Care, General Hospital Braunau, Braunau, Austria
| | - Helmut Sinzinger
- Department of Nuclear Medicine, Medical University, Vienna, Austria
| | - Barry Franklin
- Cardiac Rehabilitation and Exercise Laboratories, William Beaumont Hospital Royal Oak, MI, USA
| | - Robert Berent
- Center of Cardiac Rehabilitation, Bad Ischl, Austria
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133
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Kuller LH, Lopez OL. Preventing Dementia in Older Cardiovascular Patients. CURRENT CARDIOVASCULAR RISK REPORTS 2014. [DOI: 10.1007/s12170-014-0401-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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134
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Naci H, van Valkenhoef G, Higgins JPT, Fleurence R, Ades AE. Evidence-based prescribing: combining network meta-analysis with multicriteria decision analysis to choose among multiple drugs. Circ Cardiovasc Qual Outcomes 2014; 7:787-92. [PMID: 25097214 DOI: 10.1161/circoutcomes.114.000825] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Huseyin Naci
- From the LSE Health, Department of Social Policy, London School of Economics and Political Science, London, United Kingdom (H.N.); Drug Policy Research Group, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA (H.N.); Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (G.v.V.); School of Social and Community Medicine (J.P.T.H.) and School of Social and Community Medicine (A.E.A.), University of Bristol, Bristol, United Kingdom; Centre for Reviews and Dissemination, University of York, York, United Kingdom (J.P.T.H.); and Program on Comparative Effectiveness Research Methods and Infrastructure, Patient-Centered Outcomes Research Institute, Washington, DC (R.F.).
| | - Gert van Valkenhoef
- From the LSE Health, Department of Social Policy, London School of Economics and Political Science, London, United Kingdom (H.N.); Drug Policy Research Group, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA (H.N.); Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (G.v.V.); School of Social and Community Medicine (J.P.T.H.) and School of Social and Community Medicine (A.E.A.), University of Bristol, Bristol, United Kingdom; Centre for Reviews and Dissemination, University of York, York, United Kingdom (J.P.T.H.); and Program on Comparative Effectiveness Research Methods and Infrastructure, Patient-Centered Outcomes Research Institute, Washington, DC (R.F.)
| | - Julian P T Higgins
- From the LSE Health, Department of Social Policy, London School of Economics and Political Science, London, United Kingdom (H.N.); Drug Policy Research Group, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA (H.N.); Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (G.v.V.); School of Social and Community Medicine (J.P.T.H.) and School of Social and Community Medicine (A.E.A.), University of Bristol, Bristol, United Kingdom; Centre for Reviews and Dissemination, University of York, York, United Kingdom (J.P.T.H.); and Program on Comparative Effectiveness Research Methods and Infrastructure, Patient-Centered Outcomes Research Institute, Washington, DC (R.F.)
| | - Rachael Fleurence
- From the LSE Health, Department of Social Policy, London School of Economics and Political Science, London, United Kingdom (H.N.); Drug Policy Research Group, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA (H.N.); Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (G.v.V.); School of Social and Community Medicine (J.P.T.H.) and School of Social and Community Medicine (A.E.A.), University of Bristol, Bristol, United Kingdom; Centre for Reviews and Dissemination, University of York, York, United Kingdom (J.P.T.H.); and Program on Comparative Effectiveness Research Methods and Infrastructure, Patient-Centered Outcomes Research Institute, Washington, DC (R.F.)
| | - A E Ades
- From the LSE Health, Department of Social Policy, London School of Economics and Political Science, London, United Kingdom (H.N.); Drug Policy Research Group, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA (H.N.); Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (G.v.V.); School of Social and Community Medicine (J.P.T.H.) and School of Social and Community Medicine (A.E.A.), University of Bristol, Bristol, United Kingdom; Centre for Reviews and Dissemination, University of York, York, United Kingdom (J.P.T.H.); and Program on Comparative Effectiveness Research Methods and Infrastructure, Patient-Centered Outcomes Research Institute, Washington, DC (R.F.)
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135
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Bond H. Natural alternatives to tackling high cholesterol: guidance for community nurses. Br J Community Nurs 2014; 19:375-6, 378, 380-1. [PMID: 25089748 DOI: 10.12968/bjcn.2014.19.8.375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The National Institute for Health and Care Excellence issued its final guidance in July on lipid modification, making millions more adults eligible for statin treatment. However, community nurses may encounter many patients for whom statin use is not appropriate for a variety of reasons. This article provides advice for community nurses on methods for improving patients' cholesterol levels and reducing the risk of developing cardiovascular disease if statins are not to be used. The article explains the current situation in the UK in relation to cholesterol, then gives dietary and lifestyle modifications that may help to lower cholesterol levels and help maintain good heart and circulatory health.
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Affiliation(s)
- Helen Bond
- Registered Dietitian, Spring Vale Dietetic Clinic, Melbourne, Derbyshire
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136
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Inconsistencies and misleading information in officially approved prescribing information from three major drug markets. Clin Pharmacol Ther 2014; 96:616-24. [PMID: 25062063 DOI: 10.1038/clpt.2014.156] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 07/18/2014] [Indexed: 11/08/2022]
Abstract
The summary of product characteristics (SPC) should provide information for the safe prescription and use of a drug. We evaluated the consistency of critical interaction warnings, the quality of presentation of undesirable effects as well as concordance of critical information of representative drugs marketed in the United States, the UK, and Germany. Reciprocal warnings regarding drug-drug interactions that constitute contraindications were frequently missing in the SPCs of the drugs concerned (all countries >40%). Most SPCs did not explicitly exclude adverse reactions considered not reasonably attributable to the use of the drug. Comparing SPCs of different generic brands of the same drug, only 60, 10, and 20% of the US, UK, and German SPCs, respectively, provided identical contraindications. Current SPCs contain inconsistencies and misleading data that are not compatible with the purpose of SPCs, which is to provide a basis for the safe prescription and use of drugs.
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137
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Abstract
Statins form the pharmacologic cornerstone of the primary and secondary prevention of atherosclerotic cardiovascular disease. In addition to beneficial cardiovascular effects, statins seem to have multiple non-cardiovascular effects. Although early concerns about statin induced hepatotoxicity and cancer have subsided owing to reassuring evidence, two of the most common concerns that clinicians have are myopathy and diabetes. Randomized controlled trials suggest that statins are associated with a modest increase in the risk of myositis but not the risk of myalgia. Severe myopathy (rhabdomyolysis) is rare and often linked to a statin regimen that is no longer recommended (simvastatin 80 mg). Randomized controlled trials and meta-analyses suggest an increase in the risk of diabetes with statins, particularly with higher intensity regimens in people with two or more components of the metabolic syndrome. Other non-cardiovascular effects covered in this review are contrast induced nephropathy, cognition, cataracts, erectile dysfunction, and venous thromboembolism. Currently, systematic reviews and clinical practice guidelines indicate that the cardiovascular benefits of statins generally outweigh non-cardiovascular harms in patients above a certain threshold of cardiovascular risk. Literature is also accumulating on the potential non-cardiovascular benefits of statins, which could lead to novel applications of this class of drug in the future.
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Affiliation(s)
- Chintan S Desai
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD 21287, USA
| | - Seth S Martin
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD 21287, USA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD 21287, USA
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138
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Keen HI, Krishnarajah J, Bates TR, Watts GF. Statin myopathy: the fly in the ointment for the prevention of cardiovascular disease in the 21st century? Expert Opin Drug Saf 2014; 13:1227-39. [DOI: 10.1517/14740338.2014.937422] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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139
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Fontana M, Asaria P, Moraldo M, Finegold J, Hassanally K, Manisty CH, Francis DP. Patient-accessible tool for shared decision making in cardiovascular primary prevention: balancing longevity benefits against medication disutility. Circulation 2014; 129:2539-2546. [PMID: 24744274 DOI: 10.1161/circulationaha.113.007595] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Primary prevention guidelines focus on risk, often assuming negligible aversion to medication, yet most patients discontinue primary prevention statins within 3 years. We quantify real-world distribution of medication disutility and separately calculate the average utilities for a range of risk strata. METHOD AND RESULTS We randomly sampled 360 members of the general public in London. Medication aversion was quantified as the gain in lifespan required by each individual to offset the inconvenience (disutility) of taking an idealized daily preventative tablet. In parallel, we constructed tables of expected gain in lifespan (utility) from initiating statin therapy for each age group, sex, and cardiovascular risk profile in the population. This allowed comparison of the widths of the distributions of medication disutility and of group-average expectation of longevity gain. Observed medication disutility ranged from 1 day to >10 years of life being required by subjects (median, 6 months; interquartile range, 1-36 months) to make daily preventative therapy worthwhile. Average expected longevity benefit from statins at ages ≥50 years ranges from 3.6 months (low-risk women) to 24.3 months (high-risk men). CONCLUSION We can no longer assume that medication disutility is almost zero. Over one-quarter of subjects had disutility exceeding the group-average longevity gain from statins expected even for the highest-risk (ie, highest-gain) group. Future primary prevention studies might explore medication disutility in larger populations. Patients may differ more in disutility than in prospectively definable utility (which provides only group-average estimates). Consultations could be enriched by assessing disutility and exploring its reasons.
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Affiliation(s)
- Marianna Fontana
- International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK
| | - Perviz Asaria
- International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK
| | - Michela Moraldo
- International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK
| | - Judith Finegold
- International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK
| | - Khalil Hassanally
- International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK
| | - Charlotte H Manisty
- International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and lung Institute, Imperial College London, UK
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