Lipid-lowering therapy: strategies for improving compliance

Statin adherence in patients enrolled in the disease management program for coronary artery disease - comparison between patients' and general practitioners' self-reports and patient records

INTRODUCTION

Patients with coronary artery disease (CAD) should take a statin daily for secondary prevention. However, statin adherence in patients with CAD is low. This study investigated the proportion of adherent patients enrolled in the disease management program for CAD (DMP-CAD). Adherence was examined by comparing patients' self-reports, general practitioners' (GPs) self-reports, and prescription data.

METHODS

Between October 2019 and March 2020, all patients enrolled in the DMP-CAD in three GP practices in Germany were invited to participate in the study. Participants completed a questionnaire on the tolerability of statins. Further, prescription data from patient records, low-density lipoprotein (LDL) levels, and GPs' assessment of statin adherence were examined. The Medication Possession Ratio (MPR) served as a measurement tool for adherence.

RESULTS

Seventy-four patients were included. MPR showed high statin adherence for most patients (83.8%). However, GPs did not reliably identify non-adherence in their patients. Generally, the mean LDL values were above the guideline recommendations (97.7 ± 27.9 mg/dl), with higher values in the non-adherent (123.6 ± 42 mg/dl) than in the adherent group (93.1 ± 22 mg/dl). Non-adherent patients were more likely to be employed (41.7% vs. 11.3%).

DISCUSSION

Patients in this study showed high statin adherence. However, the LDL target value was often not reached. Therefore, GPs should take advantage of the good adherence of their patients and try to lower LDL levels by adjusting the dosage and/or changing the statin prescribed. Future studies should investigate typical characteristics of non-adherent patients in DMP-CAD so that GPs can target these patient groups and improve their adherence.

[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.

Tenfold risk increase of major cardiovascular events after high limb amputation with non-compliance for secondary prevention measures

Background The aim of the study was to evaluate the impact of compliance with lifestyle recommendations and medication on 1-year prevention of major adverse cardiovascular events (MACE) in patients with type 2 diabetes (T2D) after trans-femoral amputation (TFA). Methods In this prospective single-center interventional cohort study, 179 consecutive T2D patients with symptomatic coronary artery disease (CAD) underwent 1-year follow-up examination after TFA in 2013. Lower limb and coronary artery CT angiography were provided before surgery; physical examination and laboratory tests were performed at baseline and every month after TFA for 1 year. A total of 77 patients (43%) were defined as compliant. They followed all recommendations, including >80% drug intake (anti-diabetic, antihypertensive drugs, dual antiplatelet and statin treatment), healthy diet, smoking cessation, physical exercise ≥30 min/day. A total of 102 patients (57%) were non-compliant (drug intake ≤80%, and did not fully follow lifestyle change recommendations). Results There were no significant differences at baseline between the two groups. Fuster-BEWAT score in 1 year was 9.83 ± 3.1 in compliant and 7.74 ± 2.9 in non-compliant patients ( p = 0.0001). At 1-year follow-up, there were 43 myocardial infarctions (40 patients (93%) were non-compliant) and 28 deaths (26 cases (92.8%) were non-compliant). Patients from the non-compliant group with three- and two-vessel obstructive CAD had higher 1-year MACE rate than those with one-vessel obstructive and non-obstructive CAD (95.24% and 70.5% versus 17.2% and 8.6%; p < 0.0001); more proximal coronary lesions were related to a worse prognosis. Conclusions Non-compliant diabetic patients had a tenfold increased risk for MACE within 1 year after TFA.

The Effect of Medication Reviews in a Rural Community Pharmacy Assistance Program: The Cenla Medication Access Program

The purpose of this article is to determine the effect of mediing equations were used to assess change in PURPOSE, USE,cation reviews on patient understanding of and compliance COMPLIANCE, INTERACTION, and REACTION over time. to medications for participants in the Cenla Medication Ac All effects were adjusted for differences in age, race, gender, cess Program (CMAP). A sample of 844 individuals with a to the number of years of education, total number of medicatal of 2013 reviews over a period of 6 months to 1 year protions per patient, and the patient’s primary diagnosis. Signifiduced 5 outcome variables: the percentage of the total cant increases were observed for PURPOSE, USE, and number of drugs the patient understands the purpose of COMPLIANCE. A significant decrease was observed for (PURPOSE), understands the proper use of (USE), and is INTERACTION. No significant difference in REACTION was compliant with (COMPLIANCE) and the percentage of paobserved over time. CMAP has seen increases in patient untients that experienced any drug-drug or drug-disease interderstanding and compliance, as well as a decrease in drug-actions (INTERACTION) or any adverse reactions drug and drug-disease interactions through the first year of (REACTION). Mixed-effects models and generalized estimat medication reviews.

Is prevention a fantasy, or the future of medicine? A panoramic view of recent data, status, and direction in cardiovascular prevention

Americans are under assault by a fierce epidemic of obesity, diabetes, and cardiovascular disease, of their own doing. Lowered death rates from heart disease and reduced rates of smoking are seriously threatened by the inexorable rise in overweight and obesity. Latest data indicate that 32% of children are overweight or obese, and fewer than 17% exercise sufficiently. Over 68% of adults are overweight, 35% are obese, nearly 40% fulfill criteria for the metabolic syndrome, 8–13% have diabetes, 34% have hypertension, 36% have prehypertension, 29% have prediabetes, 15% of the population with either diabetes, hypertension, or dyslipidemia are undiagnosed, 59% engage in no vigorous activity, and fewer than 5% of the US population qualifies for the American Heart Association (AHA) definition of ideal cardiovascular health. Health, nutrition, and exercise illiteracy is prevalent, while misinformation and unrealistic expectations are the norm. Half of American adults have at least one cardiovascular risk factor. Up to 65% do not have their conventional risk biomarkers under control. Of those patients with multiple risk factors, fewer than 10% have all of them adequately controlled. Even when patients are treated according to evidence-based protocols, about 70% of cardiac events remain unaddressed. Undertreatment is also common. Poor patient adherence, probably well below 50%, adds further difficulty in reducing cardiovascular risk. Available data indicate that only a modest fraction of the total cardiovascular risk burden in the population is actually now being eliminated. A fresh view of these issues, a change in current philosophy, leading to new and different, multimechanistic methods of prevention may be needed. Adherence to published guidelines will improve substantially outcomes in both primary and secondary prevention. Primordial prevention, which does not allow risk values to appear in a population, affords more complete protection than subsequent partial reversal of elevated risk factors or biomarkers. Current evidence supports recent calls for massive educational programs supporting primordial prevention, individual responsibility and pride in achieving population-wide ideal cardiovascular health through lifestyle modification. Environmental and social changes will be necessary, along with major supportive adjustments in the food industry and the assistance of the media. Cooperation is critical to the success of such an initiative.

Impact of a compliance program on cholesterol control: results of the randomized ORBITAL study in 8108 patients treated with rosuvastatin

AIM

To determine whether a compliance-enhancing program could increase the level of lipid control in patients treated with rosuvastatin.

METHODS AND RESULTS

A total of 8108 patients (56% men, mean age 59 years; 44% women, mean age 63 years) with low-density lipoprotein cholesterol (LDL-C) >or=115 mg/dl if statin-naive or else >or=125 mg/dl were randomized to rosuvastatin 10 mg daily either with or without a compliance-enhancing program for 12 months. Patients not achieving the goal after 3 months were uptitrated to rosuvastatin 20 mg daily thereafter. At 3, 6, and 12 months, rosuvastatin plus compliance initiatives were similarly effective to rosuvastatin alone in terms of 1998 European LDL-C goal of less than 115 mg/dl achievement (72 vs. 70%, 71 vs. 69%, 68 vs. 68%) and changes in the lipid profile. Significant differences were observed in the subgroup of statin-naive patients at 3 and 6 months (80 vs. 76% and 78 vs. 73%, P<0.01). The frequency of adverse events and relevant changes in laboratory data were consistent with the known safety profile of rosuvastatin.

CONCLUSION

Rosuvastatin 10/20 mg daily enables the majority of patients to achieve LDL-C less than 115 mg/dl within 3 months. The compliance-enhancing program was only effective in statin-naive patients at early time points, but had no overall effect over 12 months.

Knowledge of heart disease risk among SHIELD respondents with dyslipidemia

BACKGROUND

Respondents in the US Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD) reported whether they had a diagnosis of dyslipidemia, were taking prescription dyslipidemia medication, and knew their heart disease risk (low, moderate, high, or do not know). We assessed whether respondents who reported a diagnosis of dyslipidemia with or without lipid-modifying treatment knew their heart disease risk and whether it correlated with National Cholesterol Education Program Adult Treatment Panel (ATP) III risk.

METHODS AND RESULTS

Based on self-report of risk factors, ATP III high risk was defined as diagnosis of heart disease/heart attack, narrow/blocked arteries, stroke, or diabetes; moderate risk included >or=2 risk factors (ie, men aged >45 years, women aged >55 years, hypertension, low high-density lipoprotein cholesterol, current smoking, and family history of CHD); and low risk included <2 risk factors. Of 7629 respondents with dyslipidemia, 35% reported not taking cholesterol medication, and 29% reported not knowing their heart disease risk. For respondents treated for dyslipidemia, 27% reported not knowing their risk, and of the 73% who reported knowing, 24% to 35% reported the same risk level as ATP III risk. For respondents with untreated dyslipidemia, 33% reported not knowing their risk, and of the 67% who reported knowing, 20% to 37% reported the same risk as ATP III risk.

CONCLUSIONS

A large proportion of respondents with dyslipidemia did not know their heart disease risk. Among those who reported knowing their risk level, >60% of respondents did not classify themselves at the same ATP III-defined risk level. There is a gap in understanding and awareness of heart disease risk among respondents with dyslipidemia regardless of treatment status.

Effect of an educational program (PEGASE) on cardiovascular risk in hypercholesterolaemic patients

BACKGROUND

Many studies have demonstrated a gap between guidelines for the prevention of cardiovascular disease (CVD) and their implementation in clinical practice.

AIM

The PEGASE education program has been devised with an aim to improve the management of patients at high risk of CVD.

METHODS

In a multicentre study carried out from 2001-2004 in France, 96 participating physicians were randomized into a "trained" group, which included 398 "educated" patients, and a "non-trained" group, which included 242 "non-educated" patients. Educated patients received six hospital-based educational sessions, four collective and two individual. Framingham score, smoking, lipid levels, glycaemia, blood pressure, dietary intake and drug compliance, as well as quality of life, were evaluated at baseline (M0) and 6 months (M6). The primary endpoint of the study was the efficacy of the PEGASE program in reducing global CVD risk in high-risk patients.

RESULTS

The Framingham score was calculated for 473 patients. The Framingham score improved significantly at M6 vs M0 in the educated group (13.0 +/- 8.21 vs 13.6 +/- 8.48, d = -0.658, p = 0.016), but not in the non-educated group (12.5 +/- 8.19 vs 12.4 +/- 7.81, d = +0.064, p = 0.836); the mean change between the two groups did not reach significance. Quality of life, LDL-c level and diet scores improved in the "educated" group only.

CONCLUSIONS

The PEGASE education program improved risk factors for CVD, although global assessment by Framingham score was not significantly different between groups. This program, aimed at meeting needs and expectations of patients and physicians, was easily implemented in all hospital centres.

Lifestyle or Life-Saving Medicines? A Primary Healthcare Professional and Consumer Opinion Survey on Over-the-Counter Statins

Background:

Over-the-counter (OTC) simvastatin 10 mg became available in the UK in July 2004 with the aim of improving primary prevention of ischemic heart disease.

Objective:

To document the views of the main stakeholders (general practitioners [GPs], community pharmacists, and consumers) on issues pertaining to the reclassification of simvastatin to OTC availability, highlight differences between stakeholder groups, and identify factors likely to influence consumer behavior.

Methods:

A self-administered questionnaire survey of GPs, community pharmacists, and potentially eligible consumers was carried out 8 months after the UK launch of OTC simvastatin. Participants were asked about their awareness of the drug, their willingness to use such medicines, and their views on relevant management practices.

Results:

Awareness of OTC simvastatin was high among GPs but limited among consumers. Although OTC availability was favored by pharmacists, consumers and GPs generally thought it was not a good idea. GPs and pharmacists cited increased consumer choice as the most important likely benefit; consumers thought potential savings to the National Health Service were equally important. Medication misuse and neglect of lifestyle risk factors were unanimously considered to be the most important likely risks. Unlike the majority of pharmacists, most GPs thought that current dosing guidelines were inappropriate, but there was consensus that long-term nonadherence would probably curtail any treatment benefit. Most respondents agreed that GPs should be informed if their patients were using OTC statins but disagreed as to the best way to communicate this information.

Conclusions:

OTC availability of statins did not appear to be considered a popular public health intervention by consumers and GPs, as the drugs were widely perceived as being prone to misuse. However, OTC availability was favored by pharmacists, who saw this as empowering both for consumers and themselves. Key issues in dispensing, managing, and evaluating the public health impact of this intervention remain outstanding.

Inverse relationship between lipid-lowering drugs and saturated fat intake in US adults

BACKGROUND

While lipid-lowering drugs reduce cardiovascular risk, there is concern that their use may discourage dietary restriction of saturated fat (SF). The purpose of this analysis was to evaluate the association between taking lipid-lowering drugs and SF intake.

MATERIALS AND METHODS

We analyzed cross-sectional data on cholesterol and diet from 6,473 adult respondents in the National Health and Nutrition Examination Survey, 1999-2002. Respondents were classified into three groups: (1) no history of high cholesterol (Desirable Cholesterol or DC), (2) history of high cholesterol without current drug treatment (Non-Drug Treated or NDT), and (3) history of high cholesterol with active lipid-lowering medication use (Drug-Treated or DT). Regression models were used to compare the mean percentage of daily kilocalories from SF among the three groups while controlling for confounders.

RESULTS

Unadjusted analyses revealed significantly lower mean daily intake of SF (% of Kcal/day) among DT respondents compared to both DC (-.40 SF; 95% Confidence Interval [CI], -0.71 to -0.08) and NDT respondents [-.36 SF; CI, -0.79 to 0.06]. The complete multivariate model controlling for all covariates (age, sex, education, race/ethnicity, current smoking, alcohol use, BMI, physical activity, cardiovascular disease, diabetes, hypertension) attenuated the relationship compared to D (-.35 SF, CI -0.7 to -0.01) and NDT (-.25 SF, CI -0.62 to 0.12) individuals.

CONCLUSION

Taking lipid-lowering medications is associated with a lower intake of SF. However, a prospective study of diet and medication use is needed to definitively evaluate the relationship between lipid-lowering medications and SF intake.

Therapeutic compliance: a prospective analysis of various factors involved in the adherence rate in type 2 diabetes

It's established that adherence rates to treatment are bad in chronic illnesses. The number of medicines prescribed and the rates of daily dosages have been shown to be of major influence for therapeutic compliance in AIDS or hypertension. Nevertheless, data on adherence to prescribed medications amongst diabetics are scarce. The aim of our study was to evaluate parameters influencing therapeutic compliance in type 2 diabetes. Adherence to treatment was evaluated by a questionnaire filled out during patient's hospitalisation in the diabetology department of a French general hospital of 450 beds. Factors influencing compliance were quantified taking into account demographic characteristics of our population, the treatments used, biological and medical data. 94 patients hospitalised for uncontrolled diabetes, aged 41-89 years, were studied. Non-adherence rate was high, 33 of them showed poor adherence to their drug treatment. Non-compliers were younger than compliant patients (56.5+/-12.1 vs. 65.5+/-12.5 years old; P<0.0001) and with a lower social position. Clinically, they were characterised by a shorter duration of diabetes and a lower number of clinical complications as macroangiopathy (6.9 vs. 33.3%; P=0.006). The number of daily doses or medicines didn't affect adherence rate. Improved control in therapeutic compliance may lead to better diabetic patients education. The implication is that instead of increasing the dose, changing the medication, or adding a second drug when glucose and HbA(1c)levels are high, clinicians should consider counselling patients on how to improve therapeutic compliance.

Trends in prescribing and utilization of statins and other lipid lowering drugs across Europe 1997-2003

AIMS

To describe trends in utilization and prescribing of statins and other lipid lowering drugs across Europe from data in routine administrative databases.

METHODS

Observational study in EU member states and Norway. Comparison of annual utilization data for lipid lowering agents by class and drug from national administrative databases for reimbursement over the period 1997-2003, measured in DDDs per 1000 inhabitants/day. Prescribed daily doses (PDD) of statins obtained from a commercial database (IMS Health) for 2000 and 2003, and used to calculate numbers of "patient treatment days" (PTD) in each country in each year. Analysis of PTD to explain increased utilization of statins.

RESULTS

Use of lipid lowering agents varied among countries (in 2003, highest in Ireland and Norway, and lowest in Italy), but increased in all countries studied (between 2000 and 2003 by 274% in Ireland and by 56% in France). This increase was entirely due to increases in statin use. Prescribed daily doses of statins increased in all countries for which data was available between 2000 and 2003, but still usually fell below the doses used in the major trials of statins. As a result, the numbers of PTDs increased to a lesser extent than suggested by utilization (e.g. by 192% in Ireland and by 35% in France). One-third of the total rise in utilization was explained by increased PDD, and two-thirds by an increase in numbers of PTDs. Statins dominated the markets in all countries, although fibrates remained strong in France and Belgium (approximately 25% of all lipid lowering agents) and to a lesser extent Germany (10%).

CONCLUSIONS

Use of statins across Europe has increased hugely over the study period. Some of the increase in use is due to higher prescribed daily doses, but two-thirds is due to increases in numbers of patient days of treatment, either due to more patients treated or less likely to better compliance.

Investigating cardiovascular risk reduction--the Rosuvastatin GALAXY Programme

The GALAXY Programme is a comprehensive global research initiative that will address several important unanswered questions in statin research and investigate the impact of rosuvastatin on cardiovascular risk reduction and patient outcomes. Studies already completed demonstrate that rosuvastatin provides greater reductions in low-density lipoprotein cholesterol (LDL-C) than other statins, enabling more patients to achieve LDL-C treatment goals. Additionally, rosuvastatin provides beneficial effects on other components of the atherogenic lipid profile. Ongoing studies will evaluate whether these effects translate into beneficial effects on atherosclerosis and significant reductions in cardiovascular events. Important information will also be provided on the role of statins in less well studied groups, including patients with heart failure, end stage renal disease, and individuals without elevated LDL-C but at heightened vascular risk as a result of increased systemic inflammation. Ultimately, the GALAXY Programme will provide clinical data that will enable physicians to make more effective statin treatment decisions, which will lead to improved patient care and cardiovascular outcomes.