Discussion around statin discontinuation in older adults and patients with wasting diseases

Patterns of Lipid Lowering Therapy Use Among Older Adults in a Managed Care Advantage Plan in the United States

Background: The prevalence of cardiovascular events is increasing. There are many new lipids lowering therapies available in recent years. Increased evidence through literature and guidelines suggests that the use of lipid lowering therapy (LLT) benefits patients who are at risk for cardiovascular events. Objective: The objective of this study was to describe the current LLT use as well as patterns of treatment modification among adults ≥ 65 years. Methods: A retrospective analysis of administrative claims data between January 2016 and May 2018 was conducted. Patients with a LLT refill and continuous enrollment during 1-year prior and 1-year follow-up were identified. The treatment episodes captured were interruption of therapy, intensity changes, dose changes, treatment augmentation, switching, and discontinuation. An analysis of treatment patterns among patients ≥75 years was also performed. Results: The study included 14,360 patients with a LLT of which 99% of patients were on statins as monotherapy or combination. Overall non-statin therapy use either as monotherapy or combination was 2.1%. There were significant differences among new initiators and existing users of therapy. Among prevalent users 57.4% had no changes in the follow-up period, 13.6% interrupted therapy, and 6.6% discontinued. Among new users, 47.9% patients had interrupted therapy, 25% had no changes, and 21.9% discontinued therapy. Conclusion: Most patients were on monotherapy and statins with low non-statin use. The new users among them were more likely to discontinue and interrupt therapy, highlighting the limitations and issues that older patients face that need to increase adherence.

A mobile health application for patients eligible for statin therapy: app development and qualitative feedback on design and usability

BACKGROUND

Cardiovascular disease is the leading cause of death in the United States (US). Despite the well-recognized efficacy of statins, statin discontinuation rates remain high. Statin intolerance is a major cause of statin discontinuation. To accurately diagnose statin intolerance, healthcare professionals must distinguish between statin-associated and non-statin-associated muscle symptoms, because many muscle symptoms can be unrelated to statin therapy. Patients' feedback on muscle-related symptoms would help providers make decisions about statin treatment. Given the potential benefits and feasibility of existing apps for cardiovascular disease (CVD) management and the unmet need for an app specifically addressing statin intolerance management, the objectives of the study were 1) to describe the developmental process of a novel app designed for patients who are eligible for statin therapy to lower the risk of CVD; 2) to explore healthcare providers' feedback of the app; and 3) to explore patients' app usage experience.

METHODS

The app was developed by an interdisciplinary team. Healthcare provider participants and patient participants were recruited in the study. Providers were interviewed to provide their feedback about the app based on screenshots of the app. Patients were interviewed after a 30 days of app usage.

RESULTS

The basic features of the app included symptom logging, vitals tracking, patient education, and push notifications. Overall, both parties provided positive feedback about the app. Areas to be improved mentioned by both parties included: the pain question asked in symptom tracking and the patient education section. Both parties agreed that it was essential to add the trend report of the logged symptoms.

CONCLUSIONS

The results indicated that providers were willing to use patient-reported data for disease management and perceived that the app had the potential to facilitate doctor-patient communication. Results also indicated that user engagement is the key to the success of app efficacy. To promote app engagement, app features should be tailored to individual patient's needs and goals. In the future, after it is upgraded, we plan to test the app usability and feasibility among a more diverse sample.

Step-by-step diagnosis and management of the nocebo/drucebo effect in statin-associated muscle symptoms patients: a position paper from the International Lipid Expert Panel (ILEP)

Statin intolerance is a clinical syndrome whereby adverse effects (AEs) associated with statin therapy [most commonly statin-associated muscle symptoms (SAMS)] result in the discontinuation of therapy and consequently increase the risk of adverse cardiovascular outcomes. However, complete statin intolerance occurs in only a small minority of treated patients (estimated prevalence of only 3-5%). Many perceived AEs are misattributed (e.g. physical musculoskeletal injury and inflammatory myopathies), and subjective symptoms occur as a result of the fact that patients expect them to do so when taking medicines (the nocebo/drucebo effect)-what might be truth even for over 50% of all patients with muscle weakness/pain. Clear guidance is necessary to enable the optimal management of plasma in real-world clinical practice in patients who experience subjective AEs. In this Position Paper of the International Lipid Expert Panel (ILEP), we present a step-by-step patient-centred approach to the identification and management of SAMS with a particular focus on strategies to prevent and manage the nocebo/drucebo effect and to improve long-term compliance with lipid-lowering therapy.

Nutraceuticals in Paediatric Patients with Dyslipidaemia

Coronary heart disease (CHD) is the main cause of death and morbidity in the world. Childhood is a critical period during which atherosclerosis may begin to develop; in the presence of familial hypercholesterolaemia (FH), the lifelong elevation of LDL cholesterol levels greatly accelerates atherosclerosis. Lowering LDL-C levels is associated with a well-documented reduction in cardiovascular disease risk. Current guidelines support the dietary and lifestyle approach as the primary strategy of intervention in children and adolescents with FH. Nutraceuticals (functional foods or dietary supplements of plant or microbial origin) are included in the EU guidelines as lifestyle interventions and may provide an additional contribution in reducing LDL levels when pharmacological therapy is not yet indicated. Meta-analyses of randomised clinical trials have demonstrated that the same nutraceuticals improve lipid profile, including lowering LDL-C, total cholesterol and triglyceride levels. In this narrative review, starting from current scientific evidence, we analyse the benefits and limitations of the nutraceuticals in children and adolescents with dyslipidaemia, and we try to evaluate their use and safety in clinical practice.

PoLA/CFPiP/PCS/PSLD/PSD/PSH guidelines on diagnosis and therapy of lipid disorders in Poland 2021

In Poland there are still nearly 20 million individuals with hypercholesterolaemia, most of them are unaware of their condition; that is also why only ca. 5% of patients with familial hypercholesterolaemia have been diagnosed; that is why other rare cholesterol metabolism disorders are so rarely diagnosed in Poland. Let us hope that these guidelines, being an effect of work of experts representing 6 main scientific societies, as well as the network of PoLA lipid centers being a part of the EAS lipid centers, certification of lipidologists by PoLA, or the growing number of centers for rare diseases, with a network planned by the Ministry of Health, improvements in coordinated care for patients after myocardial infarction (KOS-Zawał), reimbursement of innovative agents, as well as introduction in Poland of an effective primary prevention program, will make improvement in relation to these unmet needs in diagnostics and treatment of lipid disorders possible.

Bempedoic Acid: A First-in-Class Agent for Lowering Cholesterol Levels

Despite statin therapy being the cornerstone for the treatment of hypercholesterolemia, a significant number of patients do not tolerate statin therapy because of muscle-related adverse effects or cannot achieve their individual low-density lipoproteincholesterol (LDL-C) goals with statin therapy alone. Several nonstatin agents have been evaluated for the management of LDL-C levels and reduction of cardiovascular (CV) risk in these patients, but there are some limitations with their use. Bempedoic acid is a novel nonstatin agent for the management of lipid disorders, via the inhibition of adenosine triphosphate citrate lyase (ACL). It was recently approved by the US Food and Drug Administration based on several phase III trials which showed promising results regarding safety and efficacy. Though CV outcome data are not available yet, bempedoic acid may be a useful adjunct therapy for select patients. The purpose of this review is to evaluate the major findings in these clinical trials and discuss the potential role of bempedoic acid in clinical practice and its use in older people.

Association of statin use in older people primary prevention group with risk of cardiovascular events and mortality: a systematic review and meta-analysis of observational studies

BACKGROUND

Current evidence from randomized controlled trials on statins for primary prevention of cardiovascular disease (CVD) in older people, especially those aged > 75 years, is still lacking. We conducted a systematic review and meta-analysis of observational studies to extend the current evidence about the association of statin use in older people primary prevention group with risk of CVD and mortality.

METHODS

PubMed, Scopus, and Embase were searched from inception until March 18, 2021. We included observational studies (cohort or nested case-control) that compared statin use vs non-use for primary prevention of CVD in older people aged ≥ 65 years; provided that each of them reported the risk estimate on at least one of the following primary outcomes: all cause-mortality, CVD death, myocardial infarction (MI), and stroke. Risk estimates of each relevant outcome were pooled as a hazard ratio (HR) with a 95% confidence interval (CI) using the random-effects meta-analysis model. The quality of the evidence was rated using the GRADE approach.

RESULTS

Ten observational studies (9 cohorts and one case-control study; n = 815,667) fulfilled our criteria. The overall combined estimate suggested that statin therapy was associated with a significantly lower risk of all-cause mortality (HR: 0.86 [95% CI 0.79 to 0.93]), CVD death (HR: 0.80 [95% CI 0.78 to 0.81]), and stroke (HR: 0.85 [95% CI 0.76 to 0.94]) and a non-significant association with risk of MI (HR 0.74 [95% CI 0.53 to 1.02]). The beneficial association of statins with the risk of all-cause mortality remained significant even at higher ages (> 75 years old; HR 0.88 [95% CI 0.81 to 0.96]) and in both men (HR: 0.75 [95% CI: 0.74 to 0.76]) and women (HR 0.85 [95% CI 0.72 to 0.99]). However, this association with the risk of all-cause mortality remained significant only in those with diabetes mellitus (DM) (HR 0.82 [95% CI 0.68 to 0.98]) but not in those without DM. The level of evidence of all the primary outcomes was rated as "very low."

CONCLUSIONS

Statin therapy in older people (aged ≥ 65 years) without CVD was associated with a 14%, 20%, and 15% lower risk of all-cause mortality, CVD death, and stroke, respectively. The beneficial association with the risk of all-cause mortality remained significant even at higher ages (> 75 years old), in both men and women, and in individuals with DM, but not in those without DM. These observational findings support the need for trials to test the benefits of statins in those above 75 years of age.

Association between Statins Prescribed for Primary and Secondary Prevention and Major Adverse Cardiac Events among Older Adults with Frailty: A Systematic Review

BACKGROUND

Statins reduce the risk of major adverse cardiovascular events (MACE), however their clinical benefit for primary and secondary prevention among older adults with frailty is uncertain. This systematic review investigates whether statins prescribed for primary and secondary prevention are associated with reduced MACE among adults aged ≥ 65 years with frailty.

METHODS

We conducted a systematic review of studies published between 1 January 1952 and 1 January 2019 in the MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Library and International Pharmaceutical Abstracts databases. Studies that investigated the effect of statins on MACE among adults ≥ 65 years of age with a validated frailty assessment were included. Data were extracted from the papers as per a prepublished protocol, PROSPERO: CRD42019127486. Risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomised Studies of Interventions tool.

RESULTS

Six cohort studies fulfilled the inclusion criteria; there were no randomised clinical trials. Among studies evaluating the association between statins for primary and secondary prevention and mortality, one study found statins were associated with reduced mortality (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.37-0.93), while another study found they were not (HR 0.81, 95% CI 0.61-1.08). Furthermore, one study of statins used for secondary prevention found they were associated with reduced mortality (HR 0.28, 95% CI 0.21-0.39). No studies investigated the effect of statins for primary prevention or the effect of statins on the frequency of MACE.

CONCLUSION

This review identified only observational evidence that among older people with frailty, statins are associated with reduced mortality when prescribed for secondary prevention, and an absence of evidence evaluating statin therapy for primary prevention. Randomised trial data are needed to better inform the use of statins among older adults living with frailty.

The difference in referencing in Web of Science, Scopus, and Google Scholar

AIMS

How often a medical article is cited is important for many people because it is used to calculate different variables such as the h-index and the journal impact factor. The aim of this analysis was to assess how the citation count varies between Web of Science (WoS), Scopus, and Google Scholar in the current literature.

METHODS

We included the top 50 cited articles of four journals ESC Heart Failure; Journal of cachexia, sarcopenia and muscle; European Journal of Preventive Cardiology; and European Journal of Heart Failure in our analysis that were published between 1 January 2016 and 10 October 2019. We recorded the number of citations of these articles according to WoS, Scopus, and Google Scholar on 10 October 2019.

RESULTS

The top 50 articles in ESC Heart Failure were on average cited 12 (WoS), 13 (Scopus), and 17 times (Google Scholar); in Journal of cachexia, sarcopenia and muscle 37 (WoS), 43 (Scopus), and 60 times (Google Scholar); in European Journal of Preventive Cardiology 41 (WoS), 56 (Scopus), and 67 times (Google Scholar); and in European Journal of Heart Failure 76 (WoS), 108 (Scopus), and 230 times (Google Scholar). On average, the top 50 articles in all four journals were cited 41 (WoS), 52 (Scopus, 26% higher citations count than WoS, range 8-42% in the different journals), and 93 times (Google Scholar, 116% higher citation count than WoS, range 42-203%).

CONCLUSION

Scopus and Google Scholar on average have a higher citation count than WoS, whereas the difference is much larger between Google Scholar and WoS.

Group-Based Trajectory Models to Identify Sociodemographic and Clinical Predictors of Adherence Patterns to Statin Therapy Among Older Adults

BACKGROUND

The benefits of statins in the prevention of primary and secondary atherosclerotic cardiovascular (CV) disease events have been well documented. Suboptimal adherence is a persistent problem associated with increased CV events and increased healthcare utilization. Proportion of days covered (PDC) is widely used to measure medication adherence, and provides a single value that does not adequately depict different adherence behavior patterns. Group-based trajectory modeling has been used to identify adherence patterns (or trajectories) over time. The identification of characteristics unique to each pattern can help in the early identification of patients who are likely to be poor adherents and can inform the development of interventions.

OBJECTIVES

To identify distinct trajectories of statin adherence in patients enrolled in a Medicare Advantage plan and the sociodemographic and clinical predictors associated with each trajectory.

METHODS

Patients were included in the study if they were continuously enrolled in a Medicare Advantage plan between 2013 and 2016 and had a statin prescription between January 2015 and June 2015. We observed each patient for 360 days and computed the monthly PDC. The monthly PDC was incorporated into a group-based trajectory model to provide distinct patterns of adherence. Using group-based trajectory modeling, the patients were categorized into groups based on their adherence patterns. Multinomial logistic regression was performed to identify the sociodemographic and clinical factors associated with each group.

RESULTS

A total of 7850 patients were included in the analysis and were categorized into 4 distinct groups based on statin adherence-rapid discontinuation (7.8%), gradual decline (16.8%), gaps in adherence (17.2%), and high or nearly perfect adherence (58.2%). Significant predictors of being placed into one or more of the low-adherence trajectories compared with the high-adherence trajectory included sex, age, low-income subsidy, language, Charlson Comorbidity Index score, statin intensity, and 90-day refills.

CONCLUSIONS

The predictors identified in this study provide valuable insight into patient characteristics that increase the risk for statin nonadherence, which has the potential to inform targeted interventions. Identifying patient trajectories can inform the future development of protocols to individualize appropriate interventions for these patients.

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.

The Role of Nutraceuticals in Statin Intolerant Patients

Statins are the most common drugs administered for patients with cardiovascular disease. However, due to statin-associated muscle symptoms, adherence to statin therapy is challenging in clinical practice. Certain nutraceuticals, such as red yeast rice, bergamot, berberine, artichoke, soluble fiber, and plant sterols and stanols alone or in combination with each other, as well as with ezetimibe, might be considered as an alternative or add-on therapy to statins, although there is still insufficient evidence available with respect to long-term safety and effectiveness on cardiovascular disease prevention and treatment. These nutraceuticals could exert significant lipid-lowering activity and might present multiple non-lipid-lowering actions, including improvement of endothelial dysfunction and arterial stiffness, as well as anti-inflammatory and antioxidative properties. The aim of this expert opinion paper is to provide the first attempt at recommendation on the management of statin intolerance through the use of nutraceuticals with particular attention on those with effective low-density lipoprotein cholesterol reduction.

Management of Statin Intolerance in 2018: Still More Questions Than Answers

Statin therapy is generally well tolerated and very effective in the prevention and treatment of cardiovascular disease, regardless of cholesterol levels; however, it can be associated with various adverse events (myalgia, myopathy, rhabdomyolysis, and diabetes mellitus, among others). Patients frequently discontinue statin therapy without medical advice because of perceived side effects and consequently increase their risk for cardiovascular events. In patients with statin intolerance, it may be advisable to change the dose, switch to a different statin, or try an alternate-day regimen. If intolerance is associated with all statins-even at the lowest dose-non-statin drugs and certain nutraceuticals can be considered. This review focuses on the definition of statin intolerance and on the development of clinical and therapeutic strategies for its management, including emerging alternative therapies.

Statin Intolerance: Some Practical Hints

Statin intolerance is the inability to tolerate a dose of statin required to sufficiently reduce cardiovascular risk. With the five-step approach, more than 90% of these patients might be treated with statins. The principal approaches are to try not to discontinue statin therapy and to treat these patients as effectively as possible. New therapies with the proprotein convertase subtilisin-kexin type 9 inhibitors and bempedoic acid might be an effective response to these needs. In case of lack of achieved goal of the therapy nutraceuticals with confirmed low-density lipoprotein cholesterol reduction properties may be considered as a part of the lipid-lowering combination therapy.

Dyslipidaemia in the elderly: to treat or not to treat?

INTRODUCTION

The elderly population (i.e. aged ≥ 65 years) is increasing worldwide. Ageing is associated with a higher incidence and prevalence of cardiovascular disease (CVD). Areas covered: The prevalence of CVD risk factors including type 2 diabetes mellitus, hypertension and dyslipidaemia also increases with advancing age, contributing to the higher absolute CVD risk observed in the elderly. The present narrative review comments on the associations of dyslipidaemia with CVD as well as the effects of lifestyle measures and lipid-lowering drugs on lipids and CVD risk with a special focus on the elderly population. Individual treatment goals and therapeutic options according to current guidelines are also reviewed. Finally, we discuss special characteristics of the elderly that may influence the efficacy and safety of drug therapy and should be considered before selection of hypolipidaemic pharmacotherapy. Expert commentary: There may be a greater CVD benefit in older patients following drug therapy compared with younger ones. Treatment goals and therapeutic options should be individualized according to current guidelines. Specific characteristics that may influence the efficacy and safety of drug therapy in the elderly should be considered in relation to dyslipidaemia treatment.

Evaluation of dyslipidaemia and the impact of hypolipidemic therapy on prognosis in high and very high risk patients through the Hyperlipidaemia Therapy in tERtiary Cardiological cEnTer (TERCET) Registry

The use of statins in the treatment of hyperlipidaemia leads to a significant decrease in cardiovascular (CV) endpoints, and therapy effects are proportional to the reduction of cholesterol levels. In Poland, information about the effects of statin therapy is scarcely available. The information gathered in the Hyperlipidaemia Therapy in the tERtiary Cardiological cEnTer (TERCET) Registry on high-risk and very high-risk patients might improve our knowledge on this issue and help to introduce suitable activities. The main aim of the TERCET Registry is to achieve the target value of low density lipoprotein cholesterol (LDL-C) during a 1-year follow-up: LDL-C <70 mg/dL in very high-risk patients and LDL-C <100 mg/dL in high-risk patients. All consecutive patients with either stable coronary artery disease (sCAD) or acute coronary syndrome (ACS) have been included in the Registry, and the information on all-cause mortality, nonfatal myocardial infarction (MI), and planned or ACS-caused revascularisation have been being gathered within 12-month follow-up. At the moment, the TERCET Registry includes 14,873 patients (66.8% male) at an average age of 64.8 ± 10.2 with a significantly higher age of women (67.5 ± 10.3 vs. 63.5 ± 9.7; p < .001). The causes of hospitalisation were as the following: sCAD (n = 9375 patients, 63% of the investigated population), ST-elevated myocardial infarction (n = 2328 [15.6%]), non-ST-elevated myocardial infarction (n = 1700 [11.4%]), and unstable coronary artery disease (n = 1466 [10%]). 62,7% (n = 9144) of the patients were diagnosed with hyperlipidaemia before hospital admission, with no significant difference between male and female patients. The TERCET registry will allow unveiling real lipid profiles of the high- and very-high risk patients treated in the tertiary hospital. The results may play an essential role in establishing the patients' future clinical outcomes and help to assess if the lipid lowering therapy modifications changed the occurrence of CV endpoints. The registry data will summarize the number of patients unable to reach their LDL-C goals, and who in the future might become candidates suitable for new hypolipidemic therapies (ID: NCT03065543).

Casting the net broader to confirm our imaginations: the long road to treating wasting disorders

Wasting embraces muscle and tissue wasting in sarcopenia and cachexia. This article describes recent advances in the field published in the Journal of Cachexia, Sarcopenia and Muscle concerning diagnostic tools, biomarker development, pathophysiology, and treatment. Studies discussed herein embrace those on sarcopenia and cachexia in heart failure, chronic obstructive pulmonary disease, and cancer including also animal models.

An analysis of the types of recently published research in the field of cachexia

Introduction Cachexia is a common complication of many and varied chronic disease processes, yet it has received very little attention as an area of clinical research effort until recently. We sought to survey the contemporary literature on published research into cachexia to define where it is being published and the proportion of output classified into the main types of research output. Methods I searched the PubMed listings under the topic research term "cachexia" and related terms for articles published in the calendar years of 2015 and 2016, regardless of language. Searches were conducted and relevant papers extracted by two observers, and disagreements were resolved by consensus. Results There were 954 publications, 370 of which were review articles or commentaries, 254 clinical observations or non-randomised trials, 246 original basic science reports and only 26 were randomised controlled trials. These articles were published in 478 separate journals but with 36% of them being published in a core set of 23 journals. The H-index of these papers was 25 and there were 147 papers with 10 or more citations. Of the top 100 cited papers, 25% were published in five journals. Of the top cited papers, 48% were review articles, 18% were original basic science, and 7% were randomised clinical trials. Discussion This analysis shows a steady but modest increase in publications concerning cachexia with a strong pipeline of basic science research but still a relative lack of randomised clinical trials, with none exceeding 1000 patients. Research in cachexia is still in its infancy, but the solid basic science effort offers hope that translation into randomised controlled clinical trials may eventually lead to effective therapies for this troubling and complex clinical disease process.

Lipid-lowering nutraceuticals in clinical practice: position paper from an International Lipid Expert Panel

In recent years, there has been growing interest in the possible use of nutraceuticals to improve and optimize dyslipidemia control and therapy. Based on the data from available studies, nutraceuticals might help patients obtain theraputic lipid goals and reduce cardiovascular residual risk. Some nutraceuticals have essential lipid-lowering properties confirmed in studies; some might also have possible positive effects on nonlipid cardiovascular risk factors and have been shown to improve early markers of vascular health such as endothelial function and pulse wave velocity. However, the clinical evidence supporting the use of a single lipid-lowering nutraceutical or a combination of them is largely variable and, for many of the nutraceuticals, the evidence is very limited and, therefore, often debatable. The purpose of this position paper is to provide consensus-based recommendations for the optimal use of lipid-lowering nutraceuticals to manage dyslipidemia in patients who are still not on statin therapy, patients who are on statin or combination therapy but have not achieved lipid goals, and patients with statin intolerance. This statement is intended for physicians and other healthcare professionals engaged in the diagnosis and management of patients with lipid disorders, especially in the primary care setting.

[Changes in the prevalence of statin use in Germany - findings from national health interview and examination surveys 1997-1999 and 2008-2011]

BACKGROUND

Evidence-based guideline recommendations on lipid lowering drug treatment, in particular statin treatment, play an essential role in the management of dyslipidemias and in the prevention of cardiovascular disease events. In Germany, statutory health insurance data provide information on time trends in the prescription of lipid lowering drugs. However, population-based data regarding changes in user prevalence according to socio-demographic and health-related characteristics are lacking. Based on data from national health interview and examination surveys for adults in Germany 1997-1999 (GNHIES98) and 2008-2010 (DEGS1), the present analysis aims to close this information gap with a particular focus on the use of statins.

METHODS

The study population consisted of 7,099 participants (GNHIES98) and 7,091 participants (DEGS1) aged 18 to 79 years at the time of the respective surveys. Primary data on medication use within 7 days prior to the survey were collected using standardized medication interviews and brown-bag drug review. Unique product identifiers on original drug containers were scanned and coded according to the latest version of the Anatomical Therapeutic Chemical (ATC) classification system. Medical history was obtained in computer-assisted personal interviews. A history of stroke or coronary heart disease (CHD) was assessed among persons aged 40 to 79 years only, and previous stroke or CHD were defined as cardiovascular disease. Obesity was defined as a body mass index (BMI) of ≥ 30kg/m²) based on calculation from standardized measures of body weight and height. Information on socio-demographic variables and type of health insurance was collected using standardized self-administered questionnaires. In cross-sectional descriptive analyses we calculated the prevalence of statin use (ATC codes: C10AA, C10BA, C10BX) by survey as well as the changes between surveys stratified according to relevant preexisting diseases and other co-variables. The association between survey period and statin use was analyzed in multivariable binary logistic regression models among persons aged 40 to 79 years. All results were weighted and standardized for the population of 2010.

RESULTS

Between the two survey periods 1997-1999 and 2008-2011, the prevalence of statin use increased from 3.2 % to 8.8 %. The increase was most pronounced for the age group 65 to 79 years (7.2 % vs. 26.9 %) and among persons with relevant preexisting conditions, such as CHD (19.1 % vs. 54.9 %), stroke (17.1 % vs. 50.1 %), diabetes mellitus (10.5 % vs. 33.2 %), and dyslipidemia (12.6 % vs. 27.8 %). Among persons aged 40 to 79 years, the prevalence of statin use significantly increased between the two surveys, independent of co-variables (Odds Ratio: 3.70; 95 % confidence interval [CI]: 2.92 to 4.70). This applied to persons with cardiovascular disease (5.17; 3.50 to 7.64) and without cardiovascular disease (2.76; 2.07 to 3.67).

CONCLUSION

The increase in the prevalence of statin use in Germany between the two national health surveys (1997-1999 and 2008-2011) reflects the implementation of current guideline recommendations without evidence for inequalities according to gender, education, type of health insurance or region of residence. These population-based data add to information on statin prescription obtained from statutory health insurance data. Limitations of survey-based information derive from potential misclassification and selection bias as well as large time gaps between the survey periods. Further studies are needed to examine why the observed prevalence of statin use among persons with cardiovascular morbidity lags behind current guideline recommendations for secondary cardiovascular prevention.

A comparison of research into cachexia, wasting and related skeletal muscle syndromes in three chronic disease areas

INTRODUCTION

We compared the frequency of cancer, heart and lung related cachexia and cachexia-related research articles in the specialist journal, Journal of Cachexia, Sarcopenia and Muscle (JCSM) to those seen in a leading European journal in each specialist area during 2015 and 2016 to assess whether work on cachexia and related fields is relatively over or under represented in each specialist area.

RESULTS

In the dedicated journal, Journal of Cachexia, Sarcopenia and Muscle, there were 44 references related to cancer, 5 related to respiratory disease, 5 related to heart failure, and 21 related to more than one of these chronic diseases. Despite this cancer preponderance, in the European Journal of Cancer in the two publication years, there were only 5 relevant publications (0.67% of the journal output), compared to 16 (1.41%) in the European Respiratory Journal and 10 (2.19%) in the European Journal of Heart Failure.

CONCLUSIONS

There is considerable under-representation of cancer cachexia-related papers in the major European Cancer journal despite a high proportion in the dedicated cachexia journal. The under-representation is even more marked when expressed as a percentage, 0.67%, compared to 1.41% and 2.19% of the lung and heart journals respectively. These results are consistent with a worrying lack of interest in, or publication of, cachexia and related syndromes research in the cancer literature in Europe compared to its importance as a clinical syndrome. Greater interest is shown in lung and cardiology journals.

Statin-associated muscle symptoms: position paper from the Luso-Latin American Consortium

In the last two decades, statin therapy has proved to be the most potent isolated therapy for attenuation of cardiovascular risk. Its frequent use has been seen as one of the most important elements for the reduction of cardiovascular mortality in developed countries. However, the recurrent incidence of muscle symptoms in statin users raised the possibility of causal association, leading to a disease entity known as statin associated muscle symptoms (SAMS). Mechanistic studies and clinical trials, specifically designed for the study of SAMS have allowed a deeper understanding of the natural history and accurate incidence. This set of information becomes essential to avoid an unnecessary risk of severe forms of SAMS. At the same time, this concrete understanding of SAMS prevents overdiagnosis and an inadequate suspension of one of the most powerful prevention strategies of our times. In this context, the Luso-Latin American Consortium gathered all available information on the subject and presents them in detail in this document as the basis for the identification and management of SAMS.

Effects of a nutraceutical combination on lipids, inflammation and endothelial integrity in patients with subclinical inflammation: a randomized clinical trial

Cholesterol elevations are associated with systemic inflammation and endothelial fragmentation into microparticles. The cholesterol-lowering efficacy of nutraceutical combinations (NC) has not been investigated in patients with low-grade systemic inflammation and normal-borderline cholesterol levels. This is a 3-month prospective randomized open-label interventional study in patients with elevated plasma high sensitivity C-reactive protein (hsCRP) levels (>2 mg/L) and low-density lipoprotein (LDL) cholesterol of 100–160 mg/dL. The effect of either an oral cholesterol-lowering nutraceutical combination (NC) or no active treatment (noNC) was tested on LDL cholesterol, hsCRP and endothelial microparticle (EMPs) levels. Patients taking the NC had a significant reduction of total (−12%) and LDL cholesterol (−23%) compared to those who received noNC (p < 0.001 for both). Also, hsCRP and EMPs were significantly reduced by the NC (−41% and −16%, respectively). LDL cholesterol change was positively associated with hsCRP (rho = 0.21, p = 0.04) and EMP changes (rho = 0.56, p < 0.001), hsCRP and EMP changes being associated with each other (rho = 0.28, p = 0.005). Patients experiencing both LDL cholesterol and hsCRP reduction were those having the greatest EMP decrease. In conclusion, among patients with low-grade systemic inflammation, an oral NC significantly improved cholesterol profile and attenuated the degree of systemic inflammation and endothelial injury.