Statin intolerance in a referral lipid clinic

Exploring the Perceptions and Behaviours of UK Prescribers Concerning Novel Lipid-Lowering Agent Prescriptions: A Qualitative Study

Reducing low-density lipoprotein cholesterol levels lowers the risk of atherosclerotic cardiovascular disease. With the current and future portfolios of emerging lipid-lowering therapies included in various national and international guidelines, the objectives of this study were (i) to investigate the perceptions of UK prescribers', including doctors, pharmacists, and nurses, on current lipid management for cardiovascular diseases and prescriptions of novel lipid-lowering therapies, and (ii) to explore the challenges and facilitating factors of prescribing novel lipid-lowering therapies through qualitative interviews. Qualitative semi-structured interviews with twelve medical and non-medical prescribers were conducted, around 20-30 min in length. The interviews were audio-recorded and transcribed on an online platform. A thematic analysis was deployed. Four major themes emerged from the analysis: (1) prescribing barriers; (2) prescribing enablers; (3) inter-profession variability; and (4) health literacy. These themes highlighted the contrast between the need for optimal shared decision making and the various constraints in practice. Participants expressed their inexperience with novel lipid-lowering therapies and acknowledged the requirement and importance of these agents for primary cardiovascular disease prevention. Participants recognised confidence and competence as key drivers for prescribing therapies and welcomed further education and training to enhance their skillset. Patients' misconceptions towards current lipid-lowering therapies contributed to their refusal of newer agents, highlighting a requirement to improve patient education. Targeting communities through awareness campaigns was identified as a viable solution.

Efficacy and outcomes of Bempedoic acid versus placebo in patients with statin-intolerance: A pilot systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Bempedoic acid (BA) has shown significant progress in reducing cholesterol levels and is relatively free from the many side effects encountered with the use of other hyperlipidemic drugs such as statins. However, its efficacy in patients with statin intolerance is controversial with inconsistent results among studies.

MATERIALS AND METHODS

An electronic literature search was performed using various databases such as Medline, Google Scholar, and the International Registry of Clinical Trials. The primary endpoint was the change in LDL-C levels. The secondary endpoints included changes in HDL-C, non-HDL-C, triglycerides (TG), clinical outcomes such as MACE, all-cause mortality (ACM), cardiovascular mortality, myocardial infarction (MI), and additional safety outcomes. The least-square mean (LSM) percent change for assessing changes in lipid parameter levels from the baseline and the risk ratio (RR) were used for the evaluation of binary endpoints, with statistical significance set at p<0.05. Random-effects meta-analyses were performed for all the outcomes.

RESULTS

Our analysis included 5 randomized controlled trials (RCTs) with a total of 18,848 participants. BA showed a significant reduction in LDL-C [LSM difference in %: -25.24; 95 % CI: -30.79 to -19.69; p < 0.00001], total cholesterol [LSM difference in %:-21.28; 95 % CI:-30.58 to-11.98; p < 0.00001], non-HDL-C [LSM difference in %: -23.27; 95 % Cl: -29.80 to -16.73 p < 0.00001], and HDL-C [LSM difference in %:-3.37, 95 % CI:-3.73 to-3.01, p < 0.00001] compared to placebo. In terms of clinical efficacy, BA was associated with a lower risk of coronary revascularization [RR:0.81; 95 % CI:0.66 to 0.99; p = 0.04], hospitalization for unstable angina [RR:0.67; 95 % CI:0.50 to 0.88; p = 0.005], and myocardial infarction [RR:0.76; 95 % CI:0.66 to 0.88;p = 0.0004]. No significant difference was observed in MACE [RR:0.81; p = 0.15], ACM [RR:0.86; p = 0.46], cardiovascular-related mortality [RR:0.79; p = 0.44], and stroke [RR:0.83; p = 0.08] between the two groups. In terms of safety efficacy, the risk for myalgia was significantly lower in BA-treated patients than in placebo [RR:0.80; p = 0.0002], while the risk for gout [RR:1.46; p < 0.0001] and hyperuricemia [RR:1.93; p < 0.00001] was higher for BA than for placebo. The risks for other adverse effects, such as neurocognitive disorder, nasopharyngitis urinary tract infection, upper respiratory infection, muscular disorder, and worsening hyperglycemia/DM were comparable between the two groups.

CONCLUSION

Our analysis demonstrated that BA significantly reduced the levels of LDL-C, total cholesterol, non-HDL-C, HDL-C, ApoB, and hs-CRP compared with the placebo group. Additionally, patients who received BA had a lower likelihood of coronary revascularization and hospitalization due to unstable angina, MI, and myalgia. Further large-scale RCTs are required to generate more robust evidence.

Mind the Gap: Exploring Nutritional Health Compared With Weight Management Interests of Individuals with Osteoarthritis

Background

For persons with osteoarthritis (OA), nutrition education may facilitate weight and OA symptom management.

Objectives

The primary aim of this study was to determine preferred OA-related nutritional and weight management topics and their preferred delivery modality. The secondary aim was to determine whether there is a disconnect between what patients want to know about nutrition and OA management and what information health-care professionals (HCPs) are providing to patients.

Methods

The Osteoarthritis Action Alliance surveyed individuals with OA to identify their preferences, categorized in 4 domains: 1) strategies for weight management and a healthy lifestyle; 2) vitamins, minerals, and other supplements; 3) foods or nutrients that may reduce inflammation; and 4) diets for weight loss. HCPs were provided these domains and asked which topics they discussed with patients with OA. Both groups were asked to select currently utilized or preferred formats of nutritional resources.

Results

Survey responses from 338 individuals with OA and 104 HCPs were included. The highest preference rankings in each domain were: 1) foods that make OA symptoms worse (65%), foods and nutrients to reduce inflammation (57%), and healthy weight loss (42%); 2) glucosamine (53%), vitamin D (49%), and omega-3 fatty acids (45%); 3) spices and herbs (65%), fruits and vegetables (58%), and nuts (40%); and 4) Mediterranean diet (21%), low-carbohydrate diet (18%), and fasting or intermittent fasting (15%). There was greater than 20% discrepancy between interests reported by individuals with OA and discussions reported by HCPs on: weight loss strategies, general information on vitamins and minerals, special dietary considerations for other conditions, mindful eating, controlling caloric intake or portion sizes, and what foods worsen OA symptoms. Most respondents preferred to receive nutrition information in a passive format and did not want information from social media messaging.

Conclusions

There is disparity between the nutrition education content preferred by individuals with OA (which often lacks empirical support) and evidence-based topics being discussed by HCPs. HCPs must communicate evidence-based management of joint health and OA symptoms in patient-preferred formats. This study explored the information gap between what individuals with OA want to know and what HCPs believe they need to know.

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 between CVDs and initiation and adherence to statin treatment in patients with newly diagnosed hypercholesterolaemia: a retrospective cohort study

OBJECTIVES

To evaluate the association between incident cardiovascular disease (CVD) and initiation and adherence to statin treatment for primary prevention of CVD in patients with newly diagnosed hypercholesterolaemia.

DESIGN

A population-based retrospective cohort study.

SETTING

This study used National Health Insurance Service-Health Screening Cohort (NHIS-HEALS) from Republic of Korea.

PARTICIPANTS

This study included 11 320 participants without previous history of CVD aged between 40 and 79 years who had elevated total cholesterol level (more than 240 mg/dL) and had initiated statin treatment within 24 months of the national health screening from 2004 to 2012 identified in the NHIS-HEALS.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome, CVD, was defined as first-ever admission or death due to ischaemic heart disease, acute myocardial infarction, revascularisation or stroke, or December 31 2013. The HRs of CVD according to statin adherence were calculated according to stratification by Systematic COronary Risk Evaluation.

RESULTS

Early statin initiation significantly lowered risk of CVD outcomes compared with late initiation (HR of late statin user, 1.24; 95% CI 1.02 to 2.51). Among early initiators, statin discontinuers had a significantly higher risk for CVD compared with persistent users (HR, 1.71; 95% CI 1.10 to 2.67), while statin reinitiators had an attenuated risk increase (HR 1.34, 95% CI 0.79 to 2.30).

CONCLUSIONS

Among statin users with newly diagnosed hypercholesterolaemia, early statin initiation is associated with lower CVD risk compared with late initiation. Furthermore, statin discontinuation is associated with increased risk of CVD, but reinitiation attenuated the risk.

Efficacy and Safety of Bempedoic Acid in Patients With Hypercholesterolemia and Statin Intolerance

Background

Inability to tolerate statins because of muscle symptoms contributes to uncontrolled cholesterol levels and insufficient cardiovascular risk reduction. Bempedoic acid, a prodrug that is activated by a hepatic enzyme not present in skeletal muscle, inhibits ATP‐citrate lyase, an enzyme upstream of β‐hydroxy β‐methylglutaryl‐coenzyme A reductase in the cholesterol biosynthesis pathway.

Methods and Results

The phase 3, double‐blind, placebo‐controlled CLEAR (Cholesterol Lowering via Bempedoic acid, an ACL‐Inhibiting Regimen) Serenity study randomized 345 patients with hypercholesterolemia and a history of intolerance to at least 2 statins (1 at the lowest available dose) 2:1 to bempedoic acid 180 mg or placebo once daily for 24 weeks. The primary end point was mean percent change from baseline to week 12 in low‐density lipoprotein cholesterol. The mean age was 65.2 years, mean baseline low‐density lipoprotein cholesterol was 157.6 mg/dL, and 93% of patients reported a history of statin‐associated muscle symptoms. Bempedoic acid treatment significantly reduced low‐density lipoprotein cholesterol from baseline to week 12 (placebo‐corrected difference, −21.4% [95% CI, −25.1% to −17.7%]; P<0.001). Significant reductions with bempedoic acid versus placebo were also observed in non–high‐density lipoprotein cholesterol (−17.9%), total cholesterol (−14.8%), apolipoprotein B (−15.0%), and high‐sensitivity C‐reactive protein (−24.3%; P<0.001 for all comparisons). Bempedoic acid was safe and well tolerated. The most common muscle‐related adverse event, myalgia, occurred in 4.7% and 7.2% of patients who received bempedoic acid or placebo, respectively.

Conclusions

Bempedoic acid offers a safe and effective oral therapeutic option for lipid lowering in patients who cannot tolerate statins.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02988115.

See Editorial by Jia and Virani

Muscle and statins: from toxicity to the nocebo effect

INTRODUCTION

Although statins have a satisfactory safety profile and are well tolerated, many statin-treated patients report muscle symptoms in clinical practice which contribute to drug discontinuation and, consequently, adverse cardiovascular outcomes.

AREAS COVERED

This narrative review will cover the definition and prevalence of statin intolerance, the clinical spectrum of statin-associated muscle symptoms (SAMS) with special focus on patients with only mild myalgias, the complexity of statin muscle intolerance diagnosis and provide an overview on the nocebo effect of particular importance for physicians.

EXPERT OPINION

Many patients are unable to tolerate statin therapy, with SAMS being the most common cause of statin intolerance. The reported incidence of SAMS was consistently lower in randomized placebo-controlled trials than in observational studies. These results strongly suggested that SAMS were not always due to by the pharmacologic effects of statin therapy. Convincing patients that their muscle symptoms might be due to causes other than statin treatment is sometimes difficult. Furthermore, clinicians should not prematurely discontinue statin therapy before considering other possible causes, including the nocebo effect.

Formal comment on "Systematic review of the predictors of statin adherence for the primary prevention of cardiovascular disease"

Statins have been prescribed for primary prevention of cardiovascular disease (CVD) for nearly 3 decades. Throughout this period key opinion leaders in the field have been dismayed by the high rate of non-adherence of patients to follow their statin regimen. Hope et al., [1] have addressed this issue by providing a systematic review of research on predictors of statin adherence for primary prevention of CVD. However, their review does not address the ongoing debate as to whether statin treatment is warranted for primary prevention of CVD, nor does it adequately address concerns regarding adverse effects of statins. We have therefore written a commentary which provides a broader perspective on the benefits versus harms of statin therapy. Our perspective of the literature is that non-adherence to statin treatment for primary prevention of CVD is justified because the meager benefits are more than offset by the extensive harms.

The effect of high-dose atorvastatin on neural activity and cognitive function

BACKGROUND

Functional magnetic resonance imaging (fMRI) has not been used to assess the effects of statins on the brain. We assessed the effect of statins on cognition using standard neuropsychological assessments and brain neural activation with fMRI on two tasks.

METHODS

Healthy statin-naïve men and women (48±15 years) were randomized to 80 mg/day atorvastatin (n=66; 27 men) or placebo (n=84; 48 men) for 6 months. Participants completed cognitive testing while on study drug and 2 months after treatment cessation using alternative test and task versions.

RESULTS

There were few changes in standard neuropsychological tests with drug treatment (all P>.56). Total and delayed recall from the Hopkins Verbal Learning Test-Revised increased in both groups (P<.05). The Stroop Color-Word score increased (P<.01) and the 18-Point Clock Test decreased in the placebo group (P=.02) after drug cessation. There were, however, small but significant group-time interactions for each fMRI task: participants on placebo had greater activation in the right putamen/dorsal striatum during the maintenance phase of the Sternberg task while on placebo but the effect was reversed after drug washout (P<.001). Participants on atorvastatin had greater activation in the bilateral precuneus during the encoding phase of the Figural Memory task while on-drug but the effect was reversed after drug washout (P<.001).

CONCLUSION

Six months of high dose atorvastatin therapy is not associated with measurable changes in neuropsychological test scores, but did evoke transient differences in brain activation patterns. Larger, longer-term clinical trials are necessary to confirm these findings and evaluate their clinical implications.

Efficacy and safety of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, alirocumab and evolocumab, a post-commercialization study

Background

Efficacy-safety of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, alirocumab (ALI) and evolocumab (EVO), have previously been evaluated through controlled clinical trials with selective patient groups. Post-commercially, in 69 patients with heterozygous familial hypercholesterolemia (HeFH) and/or cardiovascular disease (CVD) with suboptimal LDL cholesterol (LDLC) lowering on maximal tolerated LDLC therapy, we assessed efficacy and safety of ALI and EVO.

Methods

Post-commercially, we started 29 patients on ALI 75 mg, 18 on ALI 150 mg, and 22 on EVO 140 mg every 2 weeks added to a maximally tolerated LDLC-lowering regimen. Since LDLC lowering did not differ between ALI 150 and EVO 140 mg, ALI 150-EVO 140 data were pooled (ALI-EVO). Changes in LDLC and AHA and NIH calculated 10-year CVD risks were assessed.

Results

Of the 69 patients, 25 had HeFH, 25 CVD, and 19 had both. At entry, 23 (33%) took statins and 46 (67%) were statin-intolerant. Mean ± SD and median follow-up were 49 ± 13 and 49 weeks on ALI 75 mg, and 37 ± 12 and 33 weeks on ALI-EVO. In the ALI-EVO group (n = 40), median LDLC fell from 165 mg/dl at entry to 70 mg/dl (median − 59%, p < .0001). AHA 10-year calculated CVD risk fell from 10.2 to 5.5% (median − 28%, p < .0001), and by the NIH calculator from 14.2 to 3.6% (median − 78%, p < .0001). In the ALI 75 mg group (n = 29), entry LDLC fell from 115 to 68 mg/dl (median − 39%, p < .0001). AHA 10-year calculated CVD risk fell from 11.5 to 7.3% (median − 20%, p = .004), and NIH 10-year risk from 12.9 to 5.1% (median 67%, p < .0001). Absolute and percent change in LDLC was independent of statin use. There were flu-like symptoms in 14% of patients. Adverse events did not differ (p > 0.05) between ALI 75 mg and ALI-EVO.

Conclusion

In patients with HeFH and/or CVD, LDLC decreased from 115 to 68 mg/dl (39%) on ALI 75 mg with mean follow-up of 49 weeks, and from 165 to 70 mg/dl (59%) on ALI-EVO over 37 weeks, p < .0001 for both. Adverse events were minimal and tolerable. ALI and EVO represent paradigm shifts in LDLC lowering.

Statin non-adherence and residual cardiovascular risk: There is need for substantial improvement

Although statin therapy has proven to be the cornerstone for prevention and treatment of cardiovascular disease (CVD), there are many patients for whom long-term therapy remains suboptimal. The aims of this article are to review the current complex issues associated with statin use and to explore when novel treatment approaches should be considered. Statin discontinuation as well as adherence to statin therapy remain two of the greatest challenges for lipidologists. Evidence suggests that between 40 and 75% of patients discontinue their statin therapy within one year after initiation. Furthermore, whilst the reasons for persistence with statin therapy are complex, evidence shows that low-adherence to statins negatively impacts clinical outcomes and residual CV risk remains a major concern. Non-adherence or lack of persistence with long-term statin therapy in real-life may be the main cause of inadequate low density lipoprotein cholesterol lowering with statins. There is a large need for the improvement of the use of statins, which have good safety profiles and are inexpensive. On the other hand, in a non-cost-constrained environment, proprotein convertase subtilisin/kexin type 9 inhibitors should arguably be used more often in those patients in whom treatment with statins remains unsatisfactory.