Atorvastatin Study Group in Korea. Flexible initial dosing of atorvastatin based upon initial low-density lipoprotein cholesterol levels in type 2 diabetic patients

Comparison of the effect of 40 and 80 mg/day doses of atorvastatin on changes in lipid profiles among acute coronary syndrome patients: A randomized clinical trial study

Background

Statins play a vital role in the management of high-risk patients with atherosclerotic cardiovascular disease. The aim of this study was to evaluate the effect of two doses of 40 and 80 mg of atorvastatin on lipid profiles and inflammatory markers among patients with acute coronary syndrome (ACS).

Materials and Methods

This single-blind, randomized clinical trial was conducted on 60 patients with ACS referred to Heshmatiyeh Hospital, Sabzevar, Iran. Eligible subjects were randomly assigned to either 80 mg/day (atorvastatin, 80 mg/day) or 40 mg/day intervention (atorvastatin, 40 mg/day) groups. Serum lipid profiles (low-density lipoprotein [LDL], high-density lipoprotein [HDL], triglyceride [TG], and total cholesterol), an inflammatory marker (creatine phosphokinase [CPK]), and liver function biomarkers (alanine aminotransferase, aspartate aminotransferase) were assessed before starting treatment and 3 months later.

Results

According to the paired t-test, there was a significant difference before and after intervention in each group regarding mean LDL and HDL values (P < 0.05). The result of the ANCOVA test revealed that the LDL and CPK was substantially lower in the 80 mg/day group as compared to the 40 mg/day group after 3-month intervention (62.45 ± 16.78 mg for 80 mg/day vs. 73.63 ± 20.00 for 40 mg/day P = 0.040 and 84.85 ± 6.53 IU/L for 80 mg/day vs. 120.70 ± 6.41 IU/L for 40 mg/day P = 0.001, respectively). Although the mean of HDL, TG, and cholesterol in the 80 mg/day group was lower than that of the 40 mg/day group after implementing the intervention, these differences were not statistically significant (P > 0.05).

Conclusion

Findings suggest that increasing the dose of atorvastatin decreases the mean serum levels of LDL and CPK but has no effect on the mean serum HDL levels and liver function biomarkers.

Statin Intensity and Clinical Outcome in Patients with Stable Coronary Artery Disease and Very Low LDL-Cholesterol

BACKGROUND

Although intensive statin therapy is recommended for high risk patients, evidence of its benefit in patients with stable coronary artery disease (CAD) and very low low-density lipoprotein-cholesterol (LDL-C) has been very rare. In this study, we investigated whether higher statin intensity reduces cardiovascular risks in this population.

METHODS

In this retrospective study, a total of 5234 patients with stable CAD were screened at three tertiary hospitals in Korea; 449 patients (mean age: 65 years, male: 69%) with LDL-C <80 mg/dL were finally analyzed. The statin intensities were classified according to the 2013 American College of Cardiology/American Heart Association guidelines. Patients who received statins equivalent to or weaker than atorvastatin 10 mg (group 1) were compared with those who took statins equivalent to or stronger than atorvastatin 20 mg (group 2). The impact of statin intensity on major adverse cardiac events (MACE) was evaluated during follow-up.

RESULTS

Group 1 and group 2 consisted of 181 patients (40.3%) and 268 patients (59.7%), respectively. The mean LDL-C level decreased to 52 and 57 mg/dL in group 1 and group 2, respectively, during follow-up. In a median follow-up of 4.5 years, patients of group 2 had a lower incidence of MACE (30 [16.6%] vs. 12 [4.5%], p <0.001), which were mostly related to a lower incidence of coronary revascularization. Cox proportional hazard analyses identified the statin intensity of group 2 (adjusted hazard ratio: 0.25, confidence interval: 0.11-0.55, p <0.001) and the baseline high-density lipoprotein-cholesterol level as independent determinants of MACE.

CONCLUSION

This study provides evidence that higher intensity statins are beneficial for cardiovascular outcomes in patients with stable CAD and very low LDL-C. Statins equivalent to or stronger than atorvastatin 20 mg are more effective than lower intensity statins.

Lipid-lowering efficacy of atorvastatin

BACKGROUND

This represents the first update of this review, which was published in 2012. Atorvastatin is one of the most widely prescribed drugs and the most widely prescribed statin in the world. It is therefore important to know the dose-related magnitude of effect of atorvastatin on blood lipids.

OBJECTIVES

Primary objective To quantify the effects of various doses of atorvastatin on serum total cholesterol, low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol and triglycerides in individuals with and without evidence of cardiovascular disease. The primary focus of this review was determination of the mean per cent change from baseline of LDL-cholesterol. Secondary objectives • To quantify the variability of effects of various doses of atorvastatin.• To quantify withdrawals due to adverse effects (WDAEs) in placebo-controlled randomised controlled trials (RCTs).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 11, 2013), MEDLINE (1966 to December Week 2 2013), EMBASE (1980 to December Week 2 2013), Web of Science (1899 to December Week 2 2013) and BIOSIS Previews (1969 to December Week 2 2013). We applied no language restrictions.

SELECTION CRITERIA

Randomised controlled and uncontrolled before-and-after trials evaluating the dose response of different fixed doses of atorvastatin on blood lipids over a duration of three to 12 weeks.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility criteria for studies to be included and extracted data. We collected information on withdrawals due to adverse effects from placebo-controlled trials.

MAIN RESULTS

In this update, we found an additional 42 trials and added them to the original 254 studies. The update consists of 296 trials that evaluated dose-related efficacy of atorvastatin in 38,817 participants. Included are 242 before-and-after trials and 54 placebo-controlled RCTs. Log dose-response data from both trial designs revealed linear dose-related effects on blood total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides. The Summary of findings table 1 documents the effect of atorvastatin on LDL-cholesterol over the dose range of 10 to 80 mg/d, which is the range for which this systematic review acquired the greatest quantity of data. Over this range, blood LDL-cholesterol is decreased by 37.1% to 51.7% (Summary of findings table 1). The slope of dose-related effects on cholesterol and LDL-cholesterol was similar for atorvastatin and rosuvastatin, but rosuvastatin is about three-fold more potent. Subgroup analyses suggested that the atorvastatin effect was greater in females than in males and was greater in non-familial than in familial hypercholesterolaemia. Risk of bias for the outcome of withdrawals due to adverse effects (WDAEs) was high, but the mostly unclear risk of bias was judged unlikely to affect lipid measurements. Withdrawals due to adverse effects were not statistically significantly different between atorvastatin and placebo groups in these short-term trials (risk ratio 0.98, 95% confidence interval 0.68 to 1.40).

AUTHORS' CONCLUSIONS

This update resulted in no change to the main conclusions of the review but significantly increases the strength of the evidence. Studies show that atorvastatin decreases blood total cholesterol and LDL-cholesterol in a linear dose-related manner over the commonly prescribed dose range. New findings include that atorvastatin is more than three-fold less potent than rosuvastatin, and that the cholesterol-lowering effects of atorvastatin are greater in females than in males and greater in non-familial than in familial hypercholesterolaemia. This review update does not provide a good estimate of the incidence of harms associated with atorvastatin because included trials were of short duration and adverse effects were not reported in 37% of placebo-controlled trials.

Lipid goal attainment and prescription behavior in asian patients with acute coronary syndromes: experience from a tertiary hospital

Lipid goal attainment studies in Asian patients with acute coronary syndrome (ACS) are limited. The objectives of this study were to determine low-density lipoprotein cholesterol (LDL-C) goal attainment rate at 4 months, and to examine prescription behavior influencing lipid goal attainment in Asian patients with ACS. A retrospective analysis of 267 patients with ACS was performed. The mean follow-up duration was 41.2±10.7 months. LDL-C goal attainment rate was highest at 4 months (36.7%) but declined progressively throughout follow-up. More than 85% of patients were discharged with equipotent statin dose of 2 (equivalent to simvastatin 20 mg) or less. In patients who did not attain LDL-C goals, the statin dose remained low throughout follow-up because of a lack in responsive dose titration. Aggressive lipid-lowering therapy should be initiated early to improve goal attainment in these high-risk patients.

Lipid lowering efficacy of atorvastatin

BACKGROUND

Atorvastatin is one of the most widely prescribed drugs and the most widely prescribed statin in the world. It is therefore important to know the dose-related magnitude of effect of atorvastatin on blood lipids.

OBJECTIVES

To quantify the dose-related effects of atorvastatin on blood lipids and withdrawals due to adverse effects (WDAE).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library Issue 4, 2011, MEDLINE (1966 to November 2011), EMBASE (1980 to November 2011), ISI Web of Science (1899 to November 2011) and BIOSIS Previews (1969 to November 2011). No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled and uncontrolled before-and-after trials evaluating the dose response of different fixed doses of atorvastatin on blood lipids over a duration of 3 to 12 weeks.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. WDAE information was collected from the placebo-controlled trials.

MAIN RESULTS

Two hundred fifty-four trials evaluated the dose-related efficacy of atorvastatin in 33,505 participants. Log dose-response data revealed linear dose-related effects on blood total cholesterol, low-density lipoprotein (LDL)-cholesterol and triglycerides. Combining all the trials using the generic inverse variance fixed-effect model for doses of 10 to 80 mg/day resulted in decreases of 36% to 53% for LDL-cholesterol. There was no significant dose-related effects of atorvastatin on blood high-density lipoprotein (HDL)-cholesterol. WDAE were not statistically different between atorvastatin and placebo for these short-term trials (risk ratio 0.99; 95% confidence interval 0.68 to 1.45).

AUTHORS' CONCLUSIONS

Blood total cholesterol, LDL-cholesterol and triglyceride lowering effect of atorvastatin was dependent on dose. Log dose-response data was linear over the commonly prescribed dose range. Manufacturer-recommended atorvastatin doses of 10 to 80 mg/day resulted in 36% to 53% decreases of LDL-cholesterol. The review did not provide a good estimate of the incidence of harms associated with atorvastatin because of the short duration of the trials and the lack of reporting of adverse effects in 37% of the placebo-controlled trials.

A retrospective study on the efficacy of a ten-milligram dosage of atorvastatin for treatment of hypercholesterolemia in type 2 diabetes mellitus patients

Background

There have been few clinical studies on 10 mg atorvastatin as a starting dosage for treatment of hypercholesterolemia in type 2 diabetes mellitus (T2DM) patients. This retrospective study aims to evaluate the efficacy of 10 mg dosage of atorvastatin in clinical setting.

Methods

One hundred five enrolled patients with high levels of low density lipoprotein cholesterol (LDL-C, > 100 mg/dL) took 10 mg atorvastatin. After 6 months, they were divided into 'Responder group' (LDL-C < 100 mg/dL) and 'Non-responder group' (LDL-C ≥ 100 mg/dL), and the response rate was calculated. Thereafter, we subdivided the 'Responder group' into Maintenance (10 mg), Reduced dosage (5 mg), and Discontinuance group (0 mg). The 'Non-Responder group' was subdivided into Maintenance (10 mg) and Double dosage group (20 mg). After consecutive 6 months, the response rates of each 10 mg Maintenance groups were compared to those of the other groups, respectively.

Results

Following the first 6 months, the response rate of 10 mg fixed dosage was 74.3%. In the 'Responder group', response rates of 10 mg, 5 mg and Discontinuance groups following 6 months were 52.6%, 53.1%, and 12.5%, respectively. In the 'Non-responder group', response rates of 10 mg and 20 mg groups were 28.6% and 50.0%. Baseline LDL-C levels and body mass index (BMI) of 'Responder group' were significantly lower than those of 'Non-responder group' (P = 0.004, respectively).

Conclusion

Hypercholesterolemia treatment with 10 mg, fixed dosage of atorvastatin was effective in three quarters of the subjects during the first 6-month treatment; however, a significant number of patients with high LDL-C levels and/or BMI require higher starting and maintenance dosage.

Individualized initiation of statin therapy determined by baseline LDL-C: Are you more likely to achieve goal LDL-C?

Cardiovascular disease remains the leading cause of death in the world. A significant amount of clinical data are available to demonstrate the positive influence that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) therapy has on slowing the progression of cardiovascular disease and improving clinical outcomes. Achieving the treatment goals for cholesterol in cardiovascular disease continues to present challenges. Recent clinical trial information is available assessing the use of more aggressive initial doses of statin therapy based on initial low-density lipoprotein cholesterol (LDL-C) measurements in an attempt to reach treatment goals sooner. Six clinical trials assessed low-, moderate- and high-risk individuals as well as those with type 2 diabetes mellitus to determine if this treatment approach is both safe and effective. The studies concluded that initial dosing of statin therapy determined by a baseline LDL-C measurement demonstrates good achievement in reaching treatment goals and does not result in a higher rate of adverse effects.