Adherence with statins in a real-life setting is better when associated cardiovascular risk factors increase: a cohort study

The Dynamics of Cardiovascular Risk-An Analysis of the Prospective Urban Rural Epidemiology (PURE) Poland Cohort Study

Background: The purpose of this study was to analyze the major cardiovascular risk (CVR) factors and their trends in the study population. Methods: The results of subjects in the Polish Prospective Urban and Rural Epidemiological Study (PURE) study group were interpreted. CVR was calculated for each participant according to the Systematic Coronary Risk Evaluation (SCORE2) scale or the Systematic Coronary Risk Evaluation-Older Persons (SCORE2-OP) scale. Data from the beginning of the analysis (2013) and nine years later (2022) were included. In addition, the use of lipid-lowering therapy (LLT) and meeting the low-density lipoprotein cholesterol (LDL-c) target criterion at the beginning and end of the study were analyzed. Results: Patients in the high and very high CVR groups who had abnormal LDL-c results accounted for 64% and 91% of their group in 2013 and 70% and 92% in 2022, respectively. Conclusions: Regardless of age, patients using LLT at the start of the analysis had a greater increase in future CVR, especially if they had lipid abnormalities at the start of the study. This may be due to reverse causality and multimorbidity in these patients, highlighting the importance of appropriate treatment of lipid abnormalities.

One-year care pathway after acute myocardial infarction in 2018: Prescription, medical care and medication adherence, using a French health insurance reimbursement database

BACKGROUND

Myocardial infarction is a major cause of morbidity and mortality. Guidelines have been published to optimize medical care and involve optimization of the care pathway and hospital-city coordination.

AIMS

To describe the myocardial infarction care pathway during the year following hospital discharge, and the use of and adherence to secondary prevention drugs.

METHODS

A cohort study was conducted using data from the main French health insurance reimbursement database of the ex-Aquitaine region. Information about the medical and pharmaceutical care of hospitalized patients in 2018 was collected for 12 months. Medication adherence was assessed by using the proportion of days covered by the treatment and persistence.

RESULTS

A total of 3015 patients were included, and the mean age was 66 years. Almost 76% of the patients had a reimbursement for BAS (combined prescription of beta-blocker/antiplatelet/lipid-lowering drug), BASI (combined prescription of beta-blocker/antiplatelet/lipid-lowering drug/angiotensin-converting enzyme inhibitor) or AS (combined prescription of antiplatelet/lipid-lowering drug) treatment. Medication adherence was around 83% for aspirin and 75% for lipid-lowering drugs for the 1-year persistence. During the same time, the proportion of days covered was suboptimal. Almost 4% of patients died after leaving hospital, 45% went to a cardiac rehabilitation centre and 23% had at least one hospital readmission, whatever the reason. Patients had a mean number of 11 general practitioner consultations during the year. Almost 41% of patients did not have a consultation with a cardiologist, and 38.4% had at least two consultations. Rehabilitation and general practitioner consultations were associated with adherence.

CONCLUSIONS

These new results provide clear information on the medical care environment of patients, and help us to improve care transition. Close collaboration between healthcare practitioners is very important in the early stages of outpatient follow-up.

Medication Adherence for Haemophilia Patients: Outcome of Prophylaxis Treatment Intervention

There have been various Haemophilia Treatment Centres (HTCs) set up worldwide with innovative blood factor stewardship programs. Pharmacists have been an extended part of stewardship programs providing daily rounds with haematologists, treatment plan modifications, and dosage adjustment recommendations. The Haemophilia Treatment Centres in Malaysia contain the Haemophilia Medication Therapy Adherence Clinic (HMTAC), which recruits adolescent and adult populations. There have not been any adherence studies conducted on pharmacist-steered HMTAC since initiation. The current research generates baseline data to produce treatment plans and intervention measures needed for therapy optimisation in the Malaysian population. This study also explores the relationship between medication adherence, bleeding rate, and comorbidity. This cross-sectional study involved retrospective and prospective data collection using the Validated Haemophilia Regimen Treatment Adherence Scale–Prophylaxis (VERITAS-Pro) in Ampang Hospital. The retrospective data collection included reviewing patients’ medical records, bleeding diaries, and VERITAS-Pro questionnaires pre-enrolment to HMTAC. Meanwhile, the prospective data collection was the VERITAS-Pro questionnaire administration post a minimum of three months after enrolment. The inclusion criteria were patients with severe haemophilia A and B with ages ≥18 years with self-administered prophylactic regimens for a minimum period of three months. There were six (5.8%) nonadherent participants, and 97 (94.2%) adhered to the preventive treatment. The subscale dosing and remembering and the total score of the VERITAS-Pro post-HMTAC showed a significant association with ABR. There was a significant mean reduction in the post-HMTAC compared to the pre-HMTAC score for the total score and subscales timing, remembering, skipping, and communicating. There was a significant association between the post-HMTAC adherence status and ABR. It can be concluded that the HMTAC service pioneered by the pharmacists in the National Referral Centre of Haematology is efficient in significantly improving the VERITAS-Pro scoring and then translating it into a high medication adherence rate. This study also highlights a significant correlation between post-HMTAC scores on their adherence with ABR and comorbidities.

Adherence and persistence in the use of statins and ezetimibe over 8 years in a real-life study

BACKGROUND

Adherence and persistence to treatment are crucial in statin therapy as they are synonymous with efficacy and quality of care. The aim of this study was the real-life assessment of adherence and persistence over eight years in treatment-naive patients receiving atorvastatin, lovastatin, simvastatin, pravastatin, ezetimibe.

METHODS

Adherence to treatment was calculated using the 'proportion of days covered' method and persistence as the difference between the start and end of the therapy under study.

RESULTS

Treatment adherence was consistently above 85% for all drugs under study in each year. Treatment persistence was shown to half halved already from the first year.

CONCLUSION

Adherent patients had a higher persistence than non-adherent patients.

Using group-based trajectory modeling to characterize the association of past ACEIs/ARBs adherence with subsequent statin adherence patterns among new statin users

BACKGROUND

Despite well-documented benefits, statin adherence remains suboptimal. Studies have suggested that previous adherence to other chronic medications is a strong predictor of future adherence to newly initiated statins. Group-based trajectory modeling (GBTM) has been applied as a method to longitudinally depict the dynamic nature of adherence.

OBJECTIVES

This study aimed to examine the association between patients' adherence patterns to newly initiated statins and previous adherence trajectories of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) using GBTM.

METHODS

This retrospective cohort study was conducted among continuously enrolled statin initiators using claims data. Patients were included if they had ACEI/ARB use within 1 year before statin initiation (preindex period). Monthly adherence to ACEIs/ARBs was calculated during the preindex period and monthly adherence to statins was assessed 1 year after statin initiation using proportion of days covered (PDC). The monthly PDCs were modeled as a longitudinal response in a logistic GBTM to provide distinct patterns of adherence for ACEIs/ARBs and statins, separately. A multinomial logistic regression was conducted to determine an association between ACEI/ARB adherence trajectories and future statin trajectories, controlling for patient characteristics.

RESULTS

A total of 1078 patients were categorized into 4 distinct statin adherence trajectories: adherent (40.8%), gradual decline (37.4%), gaps in adherence (13.9%), and rapid decline (7.9%). Patients were further categorized into 4 groups on the basis of their distinct past ACEIs/ARBs trajectories: adherent (43%), gaps in adherence (29%), delayed nonadherence (15.2%), and gradual decline (12.8%). In the multinomial logistic regression, patients in the gaps in adherence or gradual decline groups were more likely to follow similar trajectories for future statin use than the adherent trajectory.

CONCLUSION

Previous adherence trajectories of ACEIs/ARBs may predict future adherence patterns for newly initiated statins. Knowledge of past medication-taking behavior could provide valuable information for developing tailored interventions to improve adherence.

Long-Acting Formulations: A Promising Approach for the Treatment of Chronic Diseases

Medication and patient adherence are the two main aspects of any successful treatment of chronic disease. Even though diseases and its treatment existed for several hundred years, the treatment optimization for a given patient is still a researcher question for scientists. There are differences in treatment duration, prognostic signs and symptoms between patient to patient. Hence, designing ideal formulation to suit individual patient is a challenging task. The conventional formulations like oral solids and liquids gives a partial or incomplete treatment because the patient needs to follow the daily pills for a longer time. In such cases, the long-acting formulations will have better patient compliances as drug will be released for a longer duration. Many such approaches are under the clinical investigation. The favorable pharmacokinetic and pharmacodynamic relationships, will be promising option for the treatment of chronic diseases. In this review, we have highlighted the importance of long-acting formulations in the treatment of chronic diseases and the advent of newer formulation technologies.

Assessment of Medication Adherence in Patients with Chronic Diseases in Tabuk, Kingdom of Saudi Arabia

Objective:

Uncontrolled chronic diseases such as hypertension and diabetes mellitus can lead to severe complications. Poor adherence to medication is one of the important reasons, leading to complications for chronically diseased patients. We aimed to assess the trend toward medication adherence and the reasons for medication nonadherence in chronic disease patients in Tabuk city in Saudi Arabia.

Methods:

A cross-sectional study was conducted at a tertiary care hospital in Tabuk, Saudi Arabia. Participants were selected and interviewed for information regarding their medication adherence. A medication adherence rating scale questionnaire was used to measure the level of adherence in study participants. The data were analyzed by the statistical package for the social sciences (SPSS) database 24.

Findings:

Overall, 208 participants were involved in this study. Among these, 134 (64.4%) were female, and 74 (35.6%) were male. This study showed that 159 (76.44%) participants were adherent to their medications and nearly one-quarter of patients were nonadherent to their medications. No statistically significant differences were found between male and female patients toward their medication adherence. The primary intentional and nonintentional reason for nonadherence was side effects and forgetfulness, respectively.

Conclusion:

Tailoring the therapy according to the individual need of the patients will maximize the patient's adherence toward medications.

Determinants of Non-Adherence to the Medications for Dyslipidemia: A Systematic Review

PURPOSE

Dyslipidemia is a major cardiovascular risk factor, and its control leads to less cardiovascular events. Many patients will need some medications to achieve ideal targets. Non-adherence to medications is a complex problem with high impact on their effectiveness. This study aims to identify the determinants of non-adherence to medications in patients with dyslipidemia.

PATIENTS AND METHODS

We conducted a systematic review. PubMed and Scopus databases were searched for original articles, published between 2000 and 2020, using the MeSH terms "Dyslipidemias" and "Medication Adherence".

RESULTS

From the initial 3502 identified articles, we selected 46 to include in the final qualitative synthesis. The determinants associated with non-adherence were lower age (≤50 years), female sex, African American ethnicity, smoking habits, being a new user of lipid-lowering medications, reporting or having concerns about lipid-lowering medication side effects and some comorbidities (chronic obstructive pulmonary disease, Alzheimer's disease/dementia, depression and diabetes). On the contrary, adherence is higher in older patients, alcohol drinking habits, taking β-blockers, having a higher number of comorbidities, having a history of cardiovascular events, cardiac interventions or revascularization procedures, having health insurance and having more provider follow-up visits.

CONCLUSION

There are important identifiable determinants of non-adherence in patients with dyslipidemia. These patients benefit from a specific approach to minimize the problem and maximize the potential benefit of the prescription.

Comparison of adherence, persistence, and clinical outcome of generic and brand-name statin users: A retrospective cohort study using the Japanese claims database

BACKGROUND

Non-adherence to statin treatment results in an increased risk of cardiovascular events and all-cause mortality. This study compared adherence, persistence, and clinical outcomes of patients who initiated brand-name and generic statins in the Japanese population.

METHODS

The retrospective cohort study included adult patients who initiated statins between 2014 and 2016. Primary adherence was measured as the proportion of days covered (PDC) within 1 year. Persistence was assessed using the proportion of non-persistent users. Any major adverse cardiac and cerebrovascular event (MACCE) was assessed as a clinical outcome. Propensity score matching was performed to adjust for confounding factors.

RESULTS

Among 47,770 patients who met inclusion criteria in the study, 32,130 (67.3%) initiated generic statins. The median age of the patients was 53 (interquartile range: 46-59) years and 60.2% were male. A higher proportion of patients with PDC ≥80% [60.2% vs. 57.1%; odds ratio, 1.14; 95% confidence interval (CI), 1.09-1.19; p<0.001] and a higher PDC value (median, 90.2% vs. 87.9%; difference, 2.3%; p<0.001) were observed in the generic group. Similarly, fewer patients discontinued statins in the generic group [24.2% vs. 27.7%; hazard ratio (HR), 0.91; 95% CI, 0.87-0.95; p<0.001]. Differences in MACCE occurrence were not significant between the groups (4.3% vs. 4.2%; HR, 1.04; 95% CI, 0.93-1.17; p=0.99).

CONCLUSIONS

Adherence and persistence were higher among generic statin recipients; nevertheless, no significant differences in clinical outcomes were noted between the two groups, suggesting that generic medication did not impair treatment benefits and may improve patient adherence.

Real-world evaluation of the impact of statin intensity on adherence and persistence to therapy: A Scottish population-based study

Aim

To assess associations between statin intensity and adherence, persistence and discontinuation of statin therapy in Scotland.

Method

Retrospective cohort study, using linked electronic health records covering a period from January 2009 to December 2016. The study cohort included adult patients (≥18 years) newly initiating statins within Greater Glasgow and Clyde, Scotland. Study outcomes comprised adherence, discontinuation and persistence to treatment, stratified by three exposure groups (high, moderate and low intensity). Discontinuation and persistence were calculated using the refill‐gap and anniversary methods, respectively. Proportion of days covered (PDC) was used as a proxy for adherence. Kaplan‐Meier survival curves and Cox proportional hazard models were used to evaluate discontinuation, and associations between adherence/persistence and statin intensity were assessed using logistic regression.

Results

A total of 73 716 patients with a mean age of 61.4 ± 12.6 years were included; the majority (88.3%) received moderate intensity statins. Discontinuation rates differed between intensity levels, with high‐intensity patients less likely to discontinue treatment compared to those on moderate intensity (prior cardiovascular disease [CVD]: HR 0.43 [95% CI 0.34‐0.55]; no prior CVD: 0.80 [0.74‐0.86]). Persistence declined over time, and high‐intensity patients had the highest persistence rates. Overall, 52.6% of patients were adherent to treatment (PDC ≥ 80%), but adherence was considerably higher among high‐intensity patients (63.7%).

Conclusion

High‐intensity statins were associated with better persistence and adherence to treatment, but overall long‐term persistence and adherence remain a challenge, particularly among patients without prior CVD. This needs addressing.

Targeting the peptidase PCSK9 to reduce cardiovascular risk: Implications for basic science and upcoming challenges

LDL cholesterol (LDL-C) plays a central role in the progression of atherosclerosis. Statin therapy for lowering LDL-C reduces the risk of atherosclerotic cardiovascular disease and is the recommended first-line treatment for patients with high LDL-C levels. However, some patients are unable to achieve an adequate reduction in LDL-C with statins or are statin-intolerant; thus, PCSK9 inhibitors were developed to reduce LDL-C levels, instead of statin therapy. PCSK9 monoclonal antibodies dramatically reduce LDL-C levels and cardiovascular risk, and promising new PCSK9 inhibitors using different mechanisms are currently being developed. The absolute benefit of LDL-C reduction depends on the individual absolute risk and the achieved absolute reduction in LDL-C. Therefore, PCSK9 inhibitors may provide the greatest benefits from further LDL-C reduction for the highest risk patients. Here, we focus on PCSK9-targeted therapies and discuss the challenges of LDL-C reduction for prevention of atherosclerotic cardiovascular disease.

Statin Use and the Risk of Prostate Cancer in Ischemic Heart Disease Patients in Taiwan

Patients with ischemic heart disease (IHD) are more likely to be diagnosed with prostate cancer. Statins, which are widely used in such patients, are shown to modify the risk of prostate cancer. To clarify the association between statin use and the risk of prostate cancer among patients with higher risk of developing prostate cancer in Taiwan, a cohort of 26,628 men with IHD and aged between 55 and 100 were acquired from the National Health Insurance Research Database and followed over a period of 8 years. The risk of prostate cancer was calculated by time-dependent Cox regression model. Statin use was associated with significantly lower risk of both total and advanced prostate cancer (adjusted hazard ratio (HR): 0.719, 95% confidence interval (CI): 0.570-0.908; adjusted HR: 0.718, 95% CI: 0.530-0.972 respectively). In Taiwan IHD population, the reduction in risk of prostate cancer was observed in statin users as compared with nonusers.

Adherence to treatment of hypertension, hypercholesterolaemia and diabetes in an elderly population of a Spanish cohort

BACKGROUND AND OBJECTIVE

Sub-optimal adherence to treatment in the general population has been highlighted in several studies, especially in the elderly and/or chronic patients. This study aims to describe the adherence to treatment of diabetes mellitus, dyslipidaemia and hypertension, and to identify the factors that influence adherence.

MATERIAL AND METHOD

Retrospective, cross-sectional observational study on 16,208 patients aged ≥65 years from the EpiChron Cohort who initiated monotherapy treatment of an antidiabetic, a lipid-lowering or an antihypertensive medication in 2010. Adherence was measured by calculating the medication possession ratio during one year, considering those cases with medication possession ratio ≥80% to be adherent. We performed a descriptive study, and a logistic regression model was used to identify the predictors of low adherence.

RESULTS

Adherence to antidiabetics, antihypertensive and lipid-lowering drugs was 72.4%, 50.7% and 44.3%, respectively. An increase in adherence of 3-8% was observed for each additional chronic disease suffered by the patient. The presence of mental illness did not affect adherence, and sex, age and number of prescribed drugs did not present consistent effects.

CONCLUSION

The results obtained show a sub-optimal adherence to treatment for the 3chronic diseases studied. Adherence increased with the number of chronic diseases, while sex, age and number of drugs did not show a consistent effect. It is necessary to investigate if there are other factors that may influence therapeutic adherence, since improving adherence may have a greater impact on health than any progress in therapies.

Lipid-lowering Therapy and Goal Achievement in High-risk Patients From French General Practice

PURPOSE

The goal of this study was to summarize patterns of lipid-lowering therapy (LLT) usage and achievement of guideline-identified lipid goals in a 2015 general practice cohort of French patients with atherosclerotic cardiovascular disease (ASCVD) and/or diabetes mellitus (DM).

METHODS

From the IMS Health Real-World Data database, patients aged ≥18years were classified hierarchically into mutually exclusive categories of ASCVD subgroups and DM. LLT use and lipid goal achievement were assessed on the date of lipid measurement. The data were compared with previously published results of LLT use and lipid goal achievement in a 2014 UK population.

FINDINGS

Of 32,924 patients meeting the inclusion criteria, only 47.5% were prescribed a statin as of the index date. Hierarchically, the highest rates of use of any statin (73.3%) and high-intensity statins (43.3%) were among patients with recent acute coronary syndrome; rates in DM without ASCVD were 38.7% and 2.3%, respectively. Overall, achievement of LDL-C levels <1.8 mmol/L (<70 mg/dL) was only 13.9% for patients with ASCVD and 10.7% with DM. Relative to a 2014 UK population, the 2015 French cohort (data reanalyzed according to the UK statin categorization) were prescribed "high-dose statins" less frequently (31.4% vs 20.9%, and 18.7% vs 7.2%, for ASCVD and DM). Similarly, the proportion of patients with high-dose statins achieving LDL-C levels <1.8mmol/L was higher in the 2014 UK population than in the 2015 French population (37.3% vs 22.2%, and 36.8% vs 20.3%, for ASCVD and DM).

IMPLICATIONS

In a large cohort of French patients with ASCVD and/or DM, LLT usage and LDL-C goal achievement were suboptimal, relative to current guidelines.

Treatment gaps and potential cardiovascular risk reduction from expanded statin use in the US and England

BACKGROUND

The updated national guidelines for cardiovascular risk assessment and lipid modification in the UK and US expand the indications for statin therapy in primary prevention to adults with moderate risk of cardiovascular disease (CVD) but many adults at high CVD risk remain untreated in both countries. We set out to identify treatment gaps in English and American adults at moderate and high risk of cardiovascular disease (CVD), and to estimate the number of CVD events that would be prevented from expanding statin therapy to those who are currently untreated.

METHODS

We used nationally representative samples of 10,375 English adults and 7,687 US adults aged 40-75 years and free of existing CVD from the Health Survey for England 2009-2013, and the National Health and Nutrition Examination Survey 2007-2012 in the US. We used the risk algorithms and the risk thresholds for statin therapy recommended by each country's national guideline to categorize the survey participants into moderate-risk (≥10% to <20% 10-year risk of CVD in England and ≥7.5% to <20% risk in the US) or high-risk (≥20%risk) and simulated the number of events that would be prevented from expansion of statin therapy to those currently untreated.

RESULTS

Close to half of adults at high CVD risk in England (46.0%) and the US (49.7%) were not receiving statins. Expanding statin use to 1.45 million high-risk adults in England would save 101,000 (95% CI = 81,000-120,000) CVD events in the next 10 years compared with 128,000 (103,000-154,000) CVD events that would be prevented from expanding treatment to 3.64 million untreated moderate-risk adults. In the US, expanding statin use to 5.27 million untreated high-risk adults would save 384,000 (305,000-461,000) CVD events over 10 years compared with 616,000 (493,000-738,000) CVD events that would be prevented from treating 20.29 million untreated moderate-risk adults.

CONCLUSIONS

In both England and the US, expanding statin therapy to untreated moderate-risk adults would prevent a comparable number of events as expanding statin use to a much smaller number of currently untreated high-risk adults. A large potential for CVD prevention remains from improving coverage of statin therapy among high-risk adults.

Medication adherence in chronic illness: do beliefs about medications play a role?

BACKGROUND

Several medicines are prescribed for chronic disease management; however, adherence to long-term therapy remains poor. Culture influences beliefs about medications and, ultimately, adherence to treatment. There is a paucity of data with regard to beliefs about medications in the Middle East region, and it remains to be determined how these beliefs would impact treatment adherence.

OBJECTIVES

To investigate the relationship between patients' beliefs about medications with self-reported adherence to treatment among a chronically ill multicultural patient population.

METHODS

A prospective cross-sectional study was conducted among patients treated for chronic illnesses in the Ministry of Health primary care clinics in Kuwait. Patients completed a questionnaire that consisted of questions to collect information about their health status and demographics using validated instruments: the Beliefs about Medication, Sensitive Soma Assessment Scale, and Medication Adherence Report Scale-5 items. The main outcome measures were self-reported adherence to medications, beliefs, and perceived sensitivity toward medications.

RESULTS

Of the 1,150 questionnaires distributed, 783 were collected - giving a response rate of 68.1%. Of the 783 patients, 56.7% were male, 73.7% were married, 53.3% were non-Kuwaitis, and 49.4% had low income (<1,000 KD/3,350 USD monthly). Patients self-reported having a cardiovascular illness (80.2%), diabetes mellitus (67.7%), respiratory disease (24.3%), or mood disorder (28.6%). Participants had a mean of two comorbid illnesses and indicated taking an average of four prescription medicines to treat them. A structural equation model analysis showed adherence to medications was negatively impacted by higher negative beliefs toward medications (beta = -0.46). Factors associated with negative beliefs toward medications included marital status (being unmarried; beta = -0.14), nationality (being Kuwaiti; beta = 0.15), having lower education level (beta = -0.14), and higher illness severity (beta = 0.15). Younger age (beta = 0.10) and higher illness severity (beta = -0.9) were independently associated with lower medication adherence. Income and gender did not influence medication adherence or beliefs about medications. The combined effect of variables tested in the model explained 24% of the variance in medication adherence.

CONCLUSION

Medication adherence is a complex, multifaceted issue and patient beliefs about medications contribute significantly, although partially, to adherence among a multicultural Middle Eastern patient population.

The impact of the time of drug administration on the effectiveness of combined treatment of hypercholesterolemia with Rosuvastatin and Ezetimibe (RosEze): study protocol for a randomized controlled trial

BACKGROUND

Hypercholesterolemia is one of the main risk factors for cardiovascular disease. The first line treatment for hypercholesterolemia is statin therapy. When the expected low-density lipoprotein cholesterol (LDL-C) concentration is not achieved, the pharmacotherapy may be extended by combining the statin with the cholesterol absorption inhibitor ezetimibe.

METHODS/DESIGN

The study is designed as a randomized, open-label, single-center, crossover study evaluating the effectiveness of combined therapy with rosuvastatin and ezetimibe for hypercholesterolemia. The study is planned to include 200 patients with hypercholesterolemia ineffectively treated with statins for at least 6 weeks. After enrollment participants are randomized into one of two arms receiving rosuvastatin and ezetimibe. In the first arm the study drug is administered in the morning (8:00 am) for 6 weeks and then in the evening for the next 6 weeks; in the second arm the study drug is administered at first in the evening (8:00 pm) for the first 6 weeks and then in the morning for the following 6 weeks. In order to minimize non-adherence to the treatment, all patients will receive the study drug free of charge. The primary outcome of the study is change in LDL-C at 6 and 12 weeks of the treatment, depending on the time of day of study drug administration. The secondary endpoints include change in total cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, apolipoproteins ApoB and Apo AI, non-HDL cholesterol, small, dense (sd)-LDL cholesterol, lipoprotein(a), glucose, glycated hemoglobin, high-sensitivity C-reactive protein, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transferase, and creatine kinase at 6 and 12 weeks of the study drug treatment, as well as assessment of plasma fluorescence using stationary and time-resolved fluorescence spectroscopy at baseline and at 6 and 12 weeks of the therapy.

DISCUSSION

The RosEze trial is expected to demonstrate whether there is a significant difference in the effectiveness of the lipid-lowering therapy in reducing the concentration of cholesterol when the medications are taken in the morning compared with the evening time of day.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02772640 . Registered on 28 March 2016.

Influence of route of administration/drug formulation and other factors on adherence to treatment in rheumatoid arthritis (pain related) and dyslipidemia (non-pain related)

OBJECTIVES

A comprehensive review was performed to investigate the effect of route of administration on medication adherence and persistence in rheumatoid arthritis (RA) and to compare adherence/persistence with oral medications between RA and a non-painful disease (dyslipidemia).

RESEARCH DESIGN AND METHODS

Comprehensive database searches were performed to identify studies investigating medication adherence and/or persistence in adults with RA receiving conventional synthetic or biologic agents. Similar searches were performed for studies of patients with dyslipidemia receiving statins. Studies had to be published after 1998 in English and involve ≥6 months' follow up.

MAIN OUTCOME MEASURES

Adherence and persistence were compared between the different routes of drug administration in RA, and between the two diseases for oral medications.

RESULTS

A total of 35 and 28 papers underwent data extraction for RA and dyslipidemia, respectively. Within the constraints of the analysis, adherence and persistence rates appeared broadly similar for the different routes of drug administration in RA. Adherence to oral medications was also broadly similar across the two diseases, but persistence was lower in dyslipidemia. Poor adherence has clinical consequences in both diseases: greater disease activity and risk of flare in RA, and increased serum cholesterol levels and risk of heart and cerebrovascular disease in dyslipidemia. Over 1-3 years, poor adherence to biologic RA medications led to increased resource use and medical costs but lower total direct costs due to reduced biologic drug costs. Conversely, poor adherence to dyslipidemia medications resulted in increased total direct costs. In both diseases, adherence improved with patient education/support.

CONCLUSIONS

The route of drug administration and the symptomatic (pain) nature of the disease do not appear to be dominant factors for drug adherence or persistence in RA.

LIMITATION

The wide range of adherence and persistence values and definitions across studies made comparisons between drug formulations and diseases difficult.

A systematic review to assess adherence and persistence with statins

OBJECTIVE

To identify and assess studies published over a 10 year period up to February 2016 which measure adherence or persistence with statins, to summarize their methods, strengths and weaknesses and to summarize evidence linking statin adherence/persistence with risk of cardiovascular events.

METHODS

Electronic databases and abstracts from four major cardiovascular disease conferences were searched from January 2005 to February 2016. The study selection process was performed by two reviewers working independently. Studies were included if they reported data regarding patient adherence or persistence with statins in adults with primary hypercholesterolemia, using any type of study design or length of follow-up. One reviewer extracted the study data and assessed study quality, which was checked by a second reviewer independently. Given the heterogeneity between the included studies a narrative critique and summary is presented.

RESULTS

We report on 84 real world studies which aimed to assess adherence or persistence with statins. The majority of studies concluded that good adherence/persistence was associated with reduction in cardiovascular events and mortality. In two studies high intensity statin regimens were associated with poorer patient adherence when compared to low intensity statins. Adherence and persistence with statin therapy also has an impact on hospitalization costs and other cardiovascular disease (CVD) related costs.

CONCLUSIONS

Adherence and persistence are associated with a reduction in CVD events and mortality. There was limited evidence to suggest that high intensity statin regimens are associated with poorer treatment adherence when compared to lower intensity regimens. Hence, more robust studies are required to establish this association. As recommended by the 2013 ACC/AHA, 2016 ESC and several other clinical guidelines, clinicians and pharmacy managers should regularly monitor statin therapy adherence.

Residual cardiovascular risk in patients who received lipid-lowering treatment in a real-life setting: retrospective study

Introduction

The objective of this study was twofold: 1) to assess the residual cardiovascular (CV) risk among patients treated with statins according to guidelines and at the recommended dosages; and 2) to assess the difference, if any, in the frequency of CV events when patients were treated with other lipid-lowering agents alongside statins.

Methods

A retrospective observational study including one local health unit was conducted. Administrative databases were linked to laboratory test database in order to collect cholesterol values at baseline. Patients were included if they had filled at least one prescription for statins between January 1, 2009 and December 31, 2011; patients’ records were considered for a 12-month time span.

Results

A total of 27,330 patients treated with statins were included (50% male, mean age 68.0±11.5 years). Among them, 770 were treated with statins according to guidelines and at the recommended dosages and had a low density lipoprotein-cholesterol value below the therapeutic target. Nevertheless, the risk of myocardial infarction or stroke remained: incidence rates were 1.3±1.0 per patient per year for moderate CV risk, 4.1±2.6 for high risk, and 12.5±11.0 for very high risk. This incremental risk was confirmed further using the Cox model, by correcting for age, sex, use of antiplatelet and/or antihypertensive therapy, and adherence to treatment. As a second analysis, we compared, after a propensity score matching, patients extracted from the overall sample who were treated with fibrates. Based on the Cox model, patients on fibrates had a risk for myocardial infarction or stroke lower than patients on statins.

Conclusion

Among patients treated with statins according to guidelines and at the recommended dosages, a residual CV risk was observed. We concluded that intervention for managing residual CV risk during statin therapy should be implemented.

Factors Affecting Adherence to Statins in Hypercholesterolemic Kuwaiti Patients: A Cross-Sectional Study

OBJECTIVE

This study examined statin adherence amongst Kuwaiti hypercholesterolemic patients in order to identify factors associated with poor adherence and to determine whether or not an association exists between statin adherence and the risk profile of coronary heart disease (CHD).

SUBJECTS AND METHODS

Two hundred hypercholesterolemic patients (30-69 years of age) were recruited from Kuwaiti primary healthcare clinics and interviewed about demographic characteristics, pre-existing self-reported medical conditions and prescribed medications. The Morisky Medication Adherence Scale was used to assess statin adherence (a self-reported, medication-adherence questionnaire divided into 3 levels, with a score of 8 denoting high adherence, 6 to <8 denoting medium adherence and <6 denoting low adherence). Data regarding anthropometric, psychological and serum risk factors were collected using 2 additional questionnaires, laboratory tests and bioelectrical impedance scales. Binary logistic regression was used to determine predictors of adherence and general linear modelling was used to test relationships between continuous outcomes and statin adherence.

RESULTS

Of the 200 participants, 117 (58.5%) reported low adherence, 83 (41.5%) reported medium adherence and no patients (0%) scored high adherence. Younger patients (aged 30-50 years) had lower adherence than older patients (>50 years) [odds ratio (OR) 1.05; 95% confidence interval (CI) 1.01-1.09] for every extra year; p < 0.01). Those without diabetes, i.e. 113 (56.5%), were less likely to report medium adherence than those with diabetes (OR 0.42; 95% CI 0.23-0.75; p < 0.01). Low statin adherence was associated with higher levels of plasma cholesterol (p < 0.001) and low-density lipoprotein (p < 0.01).

CONCLUSION

In this study, there was a high prevalence of low statin adherence, especially among younger patients with fewer concomitant diseases. The results indicated an inverse relationship between statin adherence and CHD risk profile.

Using Classification and Regression Trees (CART) to Identify Prescribing Thresholds for Cardiovascular Disease

BACKGROUND AND OBJECTIVE

Many guidelines for clinical decisions are hierarchical and nonlinear. Evaluating if these guidelines are used in practice requires methods that can identify such structures and thresholds. Classification and regression trees (CART) were used to analyse prescribing patterns of Australian general practitioners (GPs) for the primary prevention of cardiovascular disease (CVD). Our aim was to identify if GPs use absolute risk (AR) guidelines in favour of individual risk factors to inform their prescribing decisions of lipid-lowering medications.

METHODS

We employed administrative prescribing information that is linked to patient-level data from a clinical assessment and patient survey (the AusHeart Study), and assessed prescribing of lipid-lowering medications over a 12-month period for patients (n = 1903) who were not using such medications prior to recruitment. CART models were developed to explain prescribing practice. Out-of-sample performance was evaluated using receiver operating characteristic (ROC) curves, and optimised via pruning.

RESULTS

We found that individual risk factors (low-density lipoprotein, diabetes, triglycerides and a history of CVD), GP-estimated rather than Framingham AR, and sociodemographic factors (household income, education) were the predominant drivers of GP prescribing. However, sociodemographic factors and some individual risk factors (triglycerides and CVD history) only become relevant for patients with a particular profile of other risk factors. The ROC area under the curve was 0.63 (95% confidence interval [CI] 0.60-0.64).

CONCLUSIONS

There is little evidence that AR guidelines recommended by the National Heart Foundation and National Vascular Disease Prevention Alliance, or conditional individual risk eligibility guidelines from the Pharmaceutical Benefits Scheme, are adopted in prescribing practice. The hierarchy of conditional relationships between risk factors and socioeconomic factors identified by CART provides new insights into prescribing decisions. Overall, CART is a useful addition to the analyst's toolkit when investigating healthcare decisions.

Does a cardiovascular event change adherence to statin treatment in patients with type 2 diabetes? A matched cohort design

OBJECTIVE

To be effective, adherence to statin treatment is essential. We assessed the effect of an apparent first cardiovascular event on statin adherence rates in type 2 diabetes patients.

RESEARCH DESIGN AND METHODS

A matched cohort study was conducted among type 2 diabetes patients initiating statin treatment for primary prevention in the Groningen University IADB.nl pharmacy database. Patients who had a drug-treated cardiovascular event (index date) after statin initiation were matched to a reference patient without such an event with similar gender, age at statin initiation, initiation date, follow-up period and adherence level before the event. Adherence rates were measured as percentages of days covered (PDC), and shifts in adherence levels (non-adherent/partially adherent/fully adherent) and rates around the event were evaluated.

RESULTS

We could match 375 of the 855 eligible index patients to a reference patient. Index patients had on average a PDC of 81% after the index date; reference patients had a PDC of 71% (p < 0.001) while both had a PDC of 79% before the index date. Index patients were 4.5 times more likely than reference patients to shift from non-adherent to fully adherent (95% CI 1.1-18.8) and 1.8 times more likely to shift from partially adherent to fully adherent (95% CI 1.2-2.6). In the index group, 26% of patients became more adherent after the first cardiovascular event. In contrast, 20% of patients became less adherent.

LIMITATIONS

Medication proxies were used, which could have caused misclassification. Furthermore, a substantial group of index patients could not be matched to a reference patient due to small ranges in matching criteria.

CONCLUSIONS

The occurrence of a drug-treated cardiovascular event appeared to avert the declining statin adherence rate observed in diabetes patients without such an event. On the other hand, one in five patients became less adherent after the event, indicating that there are still important benefits to achieve.

Statins and Nonadherence

Statin nonadherence is a major challenge to optimal management. Patients nonadherent to statin therapy do not receive the expected benefit relative to the degree of low-density lipoprotein cholesterol (LDL-C) lowering obtained. This is important because new evidence guidelines recommend statins as the first-line therapy for those in high-risk groups (secondary prevention, patients with diabetes 40-75 years of age, and LDL-C ≥ 190 mg/dL) and in selected primary prevention patients. Statin assignment in the latter group occurs only in those with an estimated ≥7.5% 10-year atherosclerotic cardiovascular disease risk after shared decision making in a clinician–patient risk discussion. However, in numerous studies, statin nonadherence shows little or no benefit in reducing cardiovascular events or mortality compared to placebo, effectively negating the risk reduction expected from statin use and concomitantly increasing the total cost of health care. The causes and solutions for nonadherence are multifactorial and include patient, clinician, and health system factors. We believe that a clinician–patient partnership that facilitates patients’ understanding of the potential for optimal benefit with the least adverse effects is an important first step toward improving adherence. A transtheoretical model of stages of behavior change helps clinicians address many of the common factors limiting adherence to statins. We conclude with a teaching tool emphasizing a structured approach to statin therapy with patient-centered risk discussions.

[Place of persistence trouble during oral contraception and subsequent use of emergency contraception]

OBJECTIVE

In order to improve the understanding of hormonal contraceptive failures, this study evaluates the persistence of oral contraception and the use of emergency contraception (EC) during persistence incidents. We made the hypothesis of the existence of a strong link between the risk of unplanned pregnancies and these two parameters. In this study, we also evaluated women's perception of EC in order to elucidate the reasons of EC insufficient use.

METHODS

One survey was carried out on Internet on a representative sample of women, aged 16-45.

RESULTS

In this survey, 3775 French women were interviewed (source-population). We defined a target population of 2415 fertile women who had heterosexual intercourse during the last 12 months, and a population of 760 women at risk of unintended pregnancy who had unprotected sexual intercourse during the last 12 months(risk-population). A little more than 30% of the target population, meaning 20% of the source-population (n=745) stopped their contraceptive method temporarily for an average time of two months. Almost 60% of women had a risk of unwanted pregnancy during this period without contraception, which is 59% of the risk-population. Only 20% of women among the population at risk used EC. The main reasons given for EC insufficient use were the misperception of the risk of pregnancy, the lack of knowledge about EC and its way of use.

CONCLUSION

For the first time, this survey shows that 13% of women (of the source population) decide to stop temporarily their contraceptive method for an average time of two months per year. Fifty-nine percent of unplanned pregnancy situations are due to this poor contraception persistence. Although there is a need to reduce the risk of women being at risk, it seems also highly desirable to overcome the consequences of this poor persistence. Giving information about EC and a systematic prescription during contraception consultations would lead to an increased use of EC.

Comparison of the risk of psychological and cognitive disorders between persistent and nonpersistent statin users

Despite their cardiovascular benefits, statin use has been associated with a wide array of actual or perceived psychological and cognitive adverse events. The objective of this study was to compare baseline characteristics and the risk of developing psychological and cognitive disorders between persistent and nonpersistent statin users. We performed a retrospective cohort study (October 1, 2003, to March 1, 2010) of 13,626 statin users in a regional US military health-care system. The persistence of statin use was defined by cumulative pharmacy fill data. Outcomes were the occurrence of psychological diseases during follow-up using prespecified groups based on International Classification of Diseases, Ninth Revision, codes: (1) schizophrenia and psychosis, (2) major depression and bipolar disorders, (3) all psychological diseases, and (4) dementia and cognitive disorders. Statin users who were nonpersistent at 2 years were younger, less likely to be men, and had fewer co-morbidities than persistent users. They were also more likely to be diagnosed with schizophrenia or psychosis (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.20 to 2.10) and cognitive disorders (OR 1.56, 95% CI 1.19 to 2.03) during follow-up compared with persistent users. There was not an association between nonpersistence at 2 years and the development of depression and bipolar disorders (OR 0.99, 95% CI 0.85 to 1.15) or combined psychological diseases (OR 0.97, 95% CI 0.86 to 1.09). Cumulative persistence with statin therapy as a continuous measure was associated with less risk of all outcomes. In conclusion, persistent statin users did not demonstrate an increase in the diagnosis of psychological disorders compared with nonpersistent users. Nonpersistent statin use was associated with a greater likelihood of being diagnosed with psychotic or cognitive disorders.

Cardiovascular risk and lifestyle habits of consumers of a phytosterol-enriched yogurt in a real-life setting

BACKGROUND

Data on the characteristics of consumers of phytosterol-enriched products and modalities of consumption are rare. An observational study evaluating the lifestyle characteristics and cardiovascular risk (CVR) profile of phytosterol-enriched yogurt consumers was performed in France.

METHODS

Subjects were recruited from general practitioners via electronic medical records. Data were obtained from 358 consumers and 422 nonconsumers with 519 subject questionnaires (243 consumers, 276 nonconsumers; 67% response).

RESULTS

Consumers had more cardiovascular risk factors than nonconsumers (2.0 ± 1.5 versus 1.6 ± 1.4; P < 0.001) and a higher 10-year SCORE cardiovascular risk (1.8 ± 2.0% versus 1.6 ± 2.2%; P = 0.008); they were older (P = 0.030) and had a higher incidence of hypercholesterolaemia (P < 0.001) and family or personal history of heart disease (P = 0.023/P = 0.026, respectively). Among consumers not on cholesterol-lowering medication, 99% were eligible for lifestyle interventions and 56% were eligible for lipid-lowering drug according to European guidelines. Consumers had a healthier lifestyle, with a higher (fruit/vegetable - saturated fatty acid) score than nonconsumers (P = 0.035), focused more on low-intensity leisure activity (P = 0.023), spent more time travelling by foot or bicycle (P = 0.012) and were more likely to act to reduce CVR. Phytosterol-enriched yogurt intake conformed to recommendations in two-thirds of consumers and was mainly consumed because of concerns over cholesterol levels and CVR.

CONCLUSIONS

The higher cardiovascular disease risk profile of phytosterol-enriched yogurt consumers corresponds to a population for whom European guidelines recommend lifestyle changes to manage cholesterol. The coherence of the data in terms of risk factors, adherence to lifestyle recommendations and the consumption of phytosterol-enriched yogurt conforming to recommendations reflects a health-conscious consumer population.

Negative impact of physician prescribed drug dosing schedule requirements on patient adherence to cardiovascular drugs

PURPOSE

The aim of this study was to determine whether dosing schedule requirements impair overall cardiovascular drug adherence.

METHODS

A cohort study was performed with hospitalized patients at high risk of cardiovascular disease between April and September 2011. Patients were asked whether the prescribed time for taking their statin and antiplatelet drugs created any inconvenience in their daily routine and, if so, were asked to describe the reasons. Patient adherence to treatment was assessed using the Morisky Medication Adherence Scale (MMAS-8). A cohort of physicians was separately studied between June and September 2011. Physicians were interviewed to determine their dosing schedule preference when prescribing statin and anti-platelet drugs, and the rationale for choosing a specific dosing schedule.

RESULTS

In the study, 103 patients and 59 physicians were included. Statins were most frequently prescribed in the evening (90%). Thienopyridines were prescribed both at lunch time (41%) and in the morning (35%). Aspirin was most frequently (65.3%) prescribed at lunch time. In total, 24.3% of patients reported being inconvenienced by their drug dosing schedule, and these subjects were less adherent to their drug regimen than those who did not report inconvenience (46.2% versus 16.7%, p = 0.014). Our results also demonstrate that there is no pharmacologic rationale for prescribing a particular drug dosing schedule for statin or anti-platelet drugs.

CONCLUSIONS

Physicians should assess patient convenience, when prescribing medication, to optimize treatment adherence.

Mortality and recurrence risk in relation to the use of lipid-lowering drugs in a prospective breast cancer patient cohort

Lipid-lowering drugs are used for the prevention of cardiovascular diseases. Statins are the most commonly used lipid-lowering drugs. Evidence from preclinical and observational studies suggests that statins might improve the prognosis of breast cancer patients. We analyzed data from the German MARIEplus study, a large prospective population-based cohort of patients aged 50 and older, who were diagnosed with breast cancer between 2001 and 2005. For overall mortality, breast-cancer specific mortality, and non-breast-cancer mortality, we included 3189 patients with invasive breast cancer stage I-IV, and for recurrence risk 3024 patients with breast cancer stage I-III. We used Cox proportional hazards models to assess the association with self-reported lipid-lowering drug use at recruitment. We stratified by study region, tumor grade, and estrogen/progesterone receptor status, and adjusted for age, tumor size, nodal status, metastases (stage I-IV only), menopausal hormone treatment, mode of detection, radiotherapy, and smoking. Mortality analyses were additionally adjusted for cardiovascular disease, diabetes mellitus and body-mass index. During a median follow-up of 5.3 years, 404 of 3189 stage I-IV patients died, and 286 deaths were attributed to breast cancer. Self-reported use of lipid-lowering drugs was non-significantly associated with increased non-breast cancer mortality (Hazard ratio (HR) 1.49, 95% confidence interval (CI) 0.88-2.52) and increased overall mortality (HR 1.21, 95% CI 0.87-1.69) whereas no association with breast cancer-specific mortality was found (HR 1.04, 0.67-1.60). Restricted to stage I-III breast cancer patients, 387 recurrences occurred during a median follow-up of 5.4 years. We found lipid-lowering drug use to be non-significantly associated with a reduced risk of recurrence (HR 0.83, 95% CI 0.54-1.24) and of breast cancer-specific mortality (HR 0.89, 95% CI 0.52-1.49). Although compatible with previous findings of an improved prognosis associated with statin use, our results do not provide clear supportive evidence for an association with lipid-lowering drug use due to imprecise estimates.

How do we improve patient compliance and adherence to long-term statin therapy?

Statins are highly effective drugs prescribed to millions of people to lower LDL-cholesterol and decrease cardiovascular risk. The benefits of statin therapy seen in randomized clinical trials will only be replicated in real-life if patients adhere to the prescribed treatment regimen. But, about half of patients discontinue statin therapy within the first year, and adherence decreases with time. Patient, physician and healthcare system-related factors play a role in this problem. Recent studies have focused more on the patients' perspectives on non-adherence. Adverse events are cited as the most common cause of statin discontinuation; thus, the healthcare provider must be willing to ally and dialogue with patients to address concerns and assess the risks and benefits of continued statin therapy.

Discontinuation of statin therapy in older people: does a cancer diagnosis make a difference? An observational cohort study using data linkage

OBJECTIVE

The aim was to examine statin discontinuation rates in a cohort of elderly Australians with newly diagnosed cancer using population-based secondary health data.

DESIGN

Observational cohort study.

SETTING

New South Wales, the largest jurisdiction in Australia. The Pharmaceutical Benefits and Repatriation Pharmaceutical Benefits Schemes are national programmes subsidising prescription drugs to the Australian population and Australian Government Department of Veterans' Affairs clients.

PARTICIPANTS

The cohort comprised 1731 cancer patients aged ≥65 years with evidence of statin use in the 90 days prior to diagnosis. They were matched to 3462 non-cancer patients prescribed statins in the same period.

MAIN OUTCOME MEASURE

The authors compared statin discontinuation rates up to 4 years post-diagnosis and examined the factors associated with statin discontinuation.

RESULTS

The proportion of cancer patients discontinuing statin therapy at 4 years (27%) was comparable to the comparison cohort; however, significantly higher proportions of the cancer cohort discontinued statins than the comparison cohort at 3, 6 and 12 months of follow-up (9.7% vs 7.4% at 12 months, respectively). More than 30% of cancer patients who died were dispensed statins within 30 days of death. Discontinuation of statin therapy in cancer patients was associated with regionalised and distant disease spread at diagnosis (p<0.001), older age (p=0.006), upper gastrointestinal organs and liver cancer (aHR 2.95, 95% CI 1.92 to 4.53) and cancer of the lung, bronchus and trachea (aHR 1.99, 95% CI 1.32 to 3.00) and poorer survival.

CONCLUSIONS

Medications should be rationalised at the time of a cancer diagnosis, especially in the setting of a poor prognosis. At least for some patients in our cohort, statin therapy may be inappropriately continued which adds unnecessarily to therapeutic burden.