LDL-C reductions and goal attainment among naive statin users in the Netherlands: real life results

Statin prescription patterns, adherence, and attainment of cholesterol treatment goals in routine clinical care: a Danish population-based study

Purpose

To examine the annual rate and cumulative prevalence of statin use in Denmark 2004–10, including adherence of use and attainment of cholesterol targets.

Methods

We included all individuals aged 18–86 years with a first statin prescription in Northern Denmark in 2004–10. We calculated the annual rate and cumulative prevalence of statin use. We examined cholesterol values before and after start of statins and the proportion reaching targets according to European guidelines and cardiovascular risk group.

Results

The study population consisted of 161,646 new statin users (51% men; median age 62 years). The peak rate of new statin initiators occurred in 2008, and a cumulative prevalence of 94 users per 1,000 population was reached in 2010. In total, 98% of new users started with simvastatin. Eighty-eight percent (142,897) did not switch statin type during follow-up. Overall persistence was 84%. The reduction in median total cholesterol in new statin users was 28% (from 6.3 mmol/L to 4.5 mmol/L), while it was 43% (from 4.0 mmol/L to 2.3 mmol/L) for low-density lipoprotein cholesterol. Among patients with very high cardiovascular risk, 66% attained the recommended total cholesterol target; corresponding figures were 74% among high-risk patients and 80% among low- to moderate-risk patients. Corresponding figures for low-density lipoprotein cholesterol were 54%, 82%, and 88%, respectively.

Conclusions

Statin use has become very prevalent in Danish adults, with high adherence. Cholesterol reduction after statin initiation is similar to that found in clinical trials, yet a substantial proportion of patients does not reach target cholesterol levels.

Comparative effectiveness of rosuvastatin versus simvastatin in primary prevention among new users: a cohort study in the French national health insurance database

Purpose

Using the French claims database (Système National d'Information Inter-Régimes de l'Assurance Maladie) linked to the hospital discharge database (Programme de Médicalisation des Systèmes d'Information), this observational study compared the effectiveness of rosuvastatin and simvastatin prescribed at doses with close LDL-cholesterol-lowering potency on all-cause mortality and cardiovascular and cerebrovascular diseases (CCDs) in primary prevention.

Methods

This historical cohort included patients with no prior CCD, aged 40–79 years, who initiated statin therapy with rosuvastatin 5 mg or simvastatin 20 mg in 2008–2009 in general practice. Follow-up started after a 1-year period used to select patients who regularly received the initial treatment.

In an intention-to-treat analysis, patients were followed up to December 2011. In a per-protocol analysis, they were censored prematurely when they discontinued their initial treatment. Adjustment for baseline covariates (age, deprivation index, comedications, comorbidities, prior hospital admissions) was carried out by a Cox proportional hazards model. In the per-protocol analysis, estimation was done by “inverse probability of censoring weighting” using additional time-dependent covariates. Analyses were gender-specific.

Results

A total of 106 941 patients initiated statin therapy with rosuvastatin 5 mg and 56 860 with simvastatin 20 mg. Mean follow-up was 35.8 months. For both genders and both types of analyses, the difference in incidence rates of mortality and/or CCD between rosuvastatin 5 mg and simvastatin 20 mg users was not statistically significant after adjustment (e.g., for CCD and/or mortality in men, in intention-to-treat analysis HR = 0.94 [95% CI = 0.85–1.04], in per-protocol analysis HR = 0.98 [0.87–1.10]).

Conclusions

The results of this real-life study based on medico-administrative databases do not support preferential prescription of rosuvastatin compared to simvastatin for primary prevention of CCD.

Cost-effectiveness of single agent, uptitration and switching statin treatment strategies for lipid lowering in Sweden

OBJECTIVES

To assess which alternative treatment strategies are optimum in terms of cost-effectiveness (EUR/patient treated to target, EUR/PTT) in lowering cholesterol in high-risk patients with elevated LDL-cholesterol (LDL-C) in Sweden.

METHODS

A probabilistic cost-effectiveness model was developed to estimate the mean expected costs and proportion of patients reaching goal attainment (defined as LDL-C < or =2.5 mmol/L [96.5 mg/dL]) at some point in time within a 52-week period following the initiation of statin therapy. Eight different statin treatment strategies were evaluated. Key data sources used in the modeling were the scientific literature, hospital tariffs and medicine price databases.

RESULTS

Depending on baseline LDL-C and the willingness-to-pay per additional PTT, the cost-effective alternative is always found among four out of the eight assessed treatment strategies (i.e. Simva10 --> Simva20 --> Simva40, Rosu10, Simva20 --> Rosu10 --> Rosu20 --> Rosu40, or Simva20 --> Simva40 --> Rosu20 --> Rosu40). An important finding was that when LDL-C level exceed 4.0 mmol/L (154mg/dL) and when willingness to pay is less than 500 EUR per additional PTT, the optimal treatment strategy would be to initiate cholesterol-lowering treatment directly with rosuvastatin 10 mg.

CONCLUSIONS

The results of this study indicate that the optimal approach to initiate lipid-lowering therapy would be to treat patients with the lower baseline LDL-C levels with the least costly treatment strategies, while initiating lipid-lowering treatment with a high-potency statin (rosuvastatin) in patients with moderately high or high baseline LDL-C levels. This recommendation can be assumed to be relevant particularly when the fact that after treatment initiation the majority of Swedish patients will not have any changes in their lipid-lowering medication or dose is taken into account. Finally, since only the short-term results are presented here, it would be valuable to conduct further studies of the long-term cost-effectiveness of different statin treatment strategies that focus on treatment persistence and LDL-C goal attainment in real practice.

Effectiveness of rosuvastatin in reducing LDL-C and target LDL-C goal attainment in real-world clinical practice

OBJECTIVE

This article reviewed the collective evidence from routine clinical practice to summarize the existing literature on the effectiveness of rosuvastatin in treating hypercholesterolemia.

METHODS

A comprehensive Medline literature search identified all published articles, in all languages, from January 2003 through September 2008 on the use of rosuvastatin in the usual-care setting. The search identified 60 articles, and 16 articles were included in this review because they were observational and non-interventional and included sufficient data specific to rosuvastatin. Excluded articles were clinical trials, cost-effectiveness models, safety, reviews, pharmacokinetics, abstracts or editorials only, or all statins combined. Included rosuvastatin articles were categorized as (1) effectiveness in general population and (2) effectiveness in special populations (e.g., elderly, diabetes).

RESULTS

Seven studies consistently showed that diverse patients from different geographic regions who were newly initiated on rosuvastatin had significantly greater reduction in low-density lipoprotein cholesterol (LDL-C) (29-52%) compared with patients treated with other statins (16-43%). LDL-C goal attainment as recommended by National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III or European Society of Cardiology (ESC) guidelines was consistently and significantly higher among patients treated with rosuvastatin (64-81%) compared with patients treated with other statins (34-73%). Rosuvastatin-treated patients with diabetes or HIV or who were elderly had significantly greater LDL-C reduction and LDL-C goal attainment compared with patients treated with other statins.

LIMITATIONS

Channeling bias or confounding by indication may have influenced the results of the real-world studies, if physicians reserve rosuvastatin for sicker or more difficult to treat patients.

CONCLUSIONS

There is a strong and consistent body of evidence demonstrating the effectiveness of rosuvastatin in lowering LDL-C and LDL-C goal attainment in real life compared with other statins at commonly prescribed doses, which reflects the existing evidence from clinical trials.

Comparison of incidences of cardiovascular events among new users of different statins: a retrospective observational cohort study

OBJECTIVE

To compare incidences of cardiovascular disease (CVD) in general and myocardial infarction (MI) specifically between new users of different statins in daily practice.

DESIGN AND METHODOLOGY

Retrospective observational cohort study. Data were obtained from the PHARMO Record Linkage System; the PHARMO database contains pharmacy dispensing records of 3 million patients in the Netherlands registered with community pharmacies, linked to hospitalisation records. The participants were new statin users in the period 2000-2005, excluding patients hospitalised for CVD events in the year prior to start of statin use.

MAIN OUTCOME MEASURES

Adjusted hazard ratios of hospitalisations for CVD (including any type of ischemic heart disease, stroke, or revascularisation procedure) in general, or MI in particular, occurring during use of the initial statin within two years of start of therapy, comparing users of different statins.

RESULTS

The mean follow-up duration of 76,147 new statin users (14,530 pravastatin, 27,752 simvastatin, 25,777 atorvastatin, 8088 rosuvastatin) was 55 weeks. Incidence rates of CVD and MI per 100 person years ranged from 0.75 and 0.15 for rosuvastatin to 1.72 and 0.29 for pravastatin. Rosuvastatin users had a lower incidence rate of CVD compared to other statin users in general (28% lower), and simvastatin (29% lower) and pravastatin users (40% lower) in particular. The difference with atorvastatin was not statistically significant. Since this was not a prospective randomised study, there is the potential for unobserved risk factors to be responsible for some of the differences observed.

CONCLUSION

Compared to other statin users without recent prior cardiovascular events, the incidence of fatal and non-fatal CVD in this retrospective observational cohort study was 28% lower among rosuvastatin users.