Cardiovascular and economic outcomes after initiation of lipid-lowering therapy with atorvastatin vs simvastatin in an employed population

Statins utilization trends and expenditures in the U.S. before and after the implementation of the 2013 ACC/AHA guidelines

Importance

Statins are drugs of choice in treating hyperlipidemia and preventing or reducing cardiovascular diseases.

Purpose

Explore statins utilization and expenditure trends in the United States before and after the publication of the 2013 ACC/AHA guidelines.

Method

A retrospective, cross-sectional study of US noninstitutionalized civilians was conducted using MEPS data from 2008 to 2019. Adults who were ≥ 40 years old and who reported taking statins were included in the study.

Primary outcomes

Statins use patterns, total cost, and out-of-pocket spending in the general adults who reported taking statins medications. Expenditures were expressed in 2019 US dollars.

Results

In this study, 409,804 individuals were eligible to be included (mean age [SE], 59 [0.1] years; 54% female). Of those participants, 22% reported taking statin therapy, and 11% of them filled only one statin prescription. The number of individuals in the general population who reported taking any statin climbed from 31 million (12%) in 2008-2009 to 92 million (35%) in 2018-2019, representing a 197% increase. After 2013, the number of individuals who used statins increased by 149%, from 37 million in 2012-2013 to 92 million users in 2018-2019. The annual number of statins prescriptions increased from 461 million to 818 million (77%; p = 0.000) between 2008 and 2019. Atorvastatin was the most prescribed medication in the statins class (36%), followed by simvastatin (34%). The moderate-intensity statins were the most used by the participants (60%). The total statins cost in 2013 was $8 billion and increased to $10 billion in 2019 (25%; p = 0.000). The total OOP expenditure trend sloped from $4.0 billion in the 2008-2009 cycle to $3.1 billion in 2018-2019. The average OOP paid by Asians was higher than that of other races at $141.

Conclusion

The proportion of individuals who used statins significantly increased following the adoption of the 2013 ACC/AHA guidelines. The findings, however, demonstrated suboptimal prescribing trends of high-intensity statins, which need to be addressed by the stakeholders to maximize medication outcomes. Statins expenditures, especially the co-payments, significantly decreased. The results have shown that revised or new regulations have a substantial impact on the healthcare industry.

Real-world Evidence for Adherence and Persistence with Atorvastatin Therapy

Atorvastatin, which has been approved by regulatory agencies for primary- and secondary-prevention patients with dyslipidemia, has historically been the most commonly prescribed statin and is now widely available in generic formulations. Despite widespread statin usage, many patients fail to attain recommended (LDL-C) targets. While several factors impact the successful treatment of dyslipidemia, suboptimal patient adherence is a major limiting factor to medication effectiveness. In this narrative review we sought to investigate patient adherence and persistence with atorvastatin in a real-world setting and to identify barriers to LDL-C goal attainment and therapy outcomes beyond the realm of clinical trials. Moreover, in light of growing generic usage, we carried out targeted literature searches to investigate the impact of generic atorvastatin availability on patient adherence/persistence, and on lipid and efficacy outcomes, compared with branded formulations. Unsurprisingly, real-world data suggest that patient adherence/persistence to atorvastatin is suboptimal, but few studies have attempted to address factors impacting adherence. Data from studies comparing adherence/persistence in patients prescribed branded or generic atorvastatin are limited and show no clear evidence that initiation of a specific preparation of atorvastatin impacts adherence/persistence. Furthermore, results from studies comparing adherence/persistence of patients who switched from the branded to the generic drug are conflicting, although they do suggest that switching may negatively impact adherence over the long term. Additional real-world studies are clearly required to understand potential differences in adherence and persistence between patients initiating treatment with branded versus generic atorvastatin and, moreover, the factors that influence adherence. Targeted education initiatives and additional research are needed to understand and improve patient adherence in a real-world setting.

Effects of simvastatin and atorvastatin on biochemical and hematological markers in patients with risk of cardiovascular diseases

OBJECTIVE

This study aimed to investigate the effects of simvastatin (SVS) and atorvastatin (AVS) on the biochemical and hematological markers in patients with risk of cardiovascular diseases.

METHODS

One hundred and fifty outpatients were enrolled from the Department of Cardiology. Patients were treated with AVS or SVS. The lipids and hematological parameters were measured at baseline and after 4-week treatment, and the risk factors of cardiovascular diseases were recorded.

RESULTS

After 4-week treatment, the lipids significantly changed. However, for hematological parameters, only mean platelet volume (MPV) significantly decreased after statins treatment (SVS: t = 68.748, P = 0.000; AVS: t = 39.472, P = 0.000), and the extent of decline was similar between SVS group and AVS group (t = 1.063, P = 0.289). There were no correlations between MPV and lipids. SVS and AVS had comparable effects on the lipid parameters after 4-week treatment, and there were no significant correlations of ΔMPV with the Δtotal cholesterol, Δhigh density lipoprotein-cholesterol, Δlow density lipoprotein-cholesterol, Δtriglyceride, Δapolipoproteint A1, Δapolipoproteint B and Δlipoproteint (a) after treatments (all P > 0.05).

CONCLUSION

After statins treatment, the lipids significantly change; only MPV significantly decreases among hematological parameters, but it has no relationship with lipids reduction. The synthetic atorvastatin has similar effects to native simvastatin in the management of patients with risk for cardiovascular diseases.

Atorvastatin reduces endotoxin-induced microvascular inflammation via NOSII

In a lipopolysaccharide (LPS)-induced rat model of sepsis (endotoxaemia), we previously demonstrated that pravastatin reduced microvascular inflammation via increased endothelial nitric oxide synthase III (NOSIII). This study aimed to determine whether atorvastatin, the most commonly used statin for lowering cholesterol, exerted beneficial pleiotropic effects via a similar mechanism. The mesenteric microcirculation of anaesthetised male Wistar rats (308 ± 63 g, n = 54) was prepared for fluorescent intravital microscopy. Over 4 h, animals received intravenous (i.v.) administration of either saline, LPS (150 μg kg(-1) h(-1)) or LPS + atorvastatin (200 μg kg(-1) s.c., 18 and 3 h before LPS), with/without the non-specific NOS inhibitor L-NG-Nitroarginine Methyl Ester (L-NAME) (10 μg kg(-1) h(-1)) or NOSII-specific inhibitor 1400 W (20 μg kg(-1) min(-1)). LPS decreased mean arterial blood pressure (MAP) (4 h, control 113 ± 20 mmHg; LPS 70 ± 23 mmHg), being reversed by atorvastatin (105 ± 3 mmHg) (p < 0.05). LPS also increased macromolecular leak measured after 100 mg kg(-1) of i.v FITC-BSA (arbitrary grey level adjacent to venules), which again was attenuated by atorvastatin (control 1.9 ± 4.0; LPS 12.0 ± 2.4; LPS + atorvastatin 4.5 ± 2.2) (p < 0.05). Furthermore, immunohistochemistry identified that atorvastatin decreased LPS-induced upregulation of endothelial cell NOSII expression, but NOSIII was unchanged in all groups. Atorvastatin improved MAP and reduced microvascular inflammation during endotoxaemia, associated with a reduction of pro-inflammatory NOSII. This differs from previous studies, whereby pravastatin increased expression of NOSIII. Thus preoperative statins have beneficial anti-inflammatory effects during endotoxaemia, but careful consideration must be given to the specific statin being used.

Sequential cohort design applying propensity score matching to analyze the comparative effectiveness of atorvastatin and simvastatin in preventing cardiovascular events

Background

Sequential cohort design (SCD) applying matching for propensity scores (PS) in accrual periods has been proposed to mitigate bias caused by channeling when calendar time is a proxy for strong confounders. We studied the channeling of patients according to atorvastatin and simvastatin initiation in Finland, starting from the market introduction of atorvastatin in 1998, and explored the SCD PS approach to analyzing the comparative effectiveness of atorvastatin versus simvastatin in the prevention of cardiovascular events (CVE).

Methods

Initiators of atorvastatin or simvastatin use in the 45–75-year age range in 1998–2006 were characterized by their propensity of receiving atorvastatin over simvastatin, as estimated for 17 six-month periods. Atorvastatin (10 mg) and simvastatin (20 mg) initiators were matched 1∶1 on the PS, as estimated for the whole cohort and within each period. Cox regression models were fitted conventionally, and also for the PS matched cohort and the periodically PS matched cohort, to estimate the hazard ratios (HR) for CVEs.

Findings

Atorvastatin (10 mg) was associated with a 11%–12% lower incidence of CVE in comparison with simvastatin (20 mg). The HR estimates were the same for a conventional Cox model (0.88, 95% confidence interval 0.85–0.91), for the analysis in which the PS was used to match across all periods and the Cox model was adjusted for strong confounders (0.89, 0.85–0.92), and for the analysis in which PS matching was applied within sequential periods (0.88, 0.84–0.92). The HR from a traditional PS matched analysis was 0.80 (0.77–0.83).

Conclusions

The SCD PS approach produced effect estimates similar to those obtained in matching for PS within the whole cohort and adjusting the outcome model for strong confounders, but at the cost of efficiency. A traditional PS matched analysis without further adjustment in the outcome model produced estimates further away from unity.

Cardiovascular and economic outcomes after initiation of atorvastatin versus simvastatin in an employed population stratified by cardiovascular risk

The relative effects of atorvastatin and simvastatin among higher- and lower-risk patients are not well characterized. This study compared cardiovascular (CV) risk and direct and indirect costs among higher- and lower-risk employees initiating atorvastatin vs. simvastatin. Using a large employer claims database (1999-2006), employees were stratified as 1) high-risk employees with prior CV events, diabetes, or renal disorders; and 2) low- to intermediate-risk employees without these conditions. Propensity score matching was used, and 2-year outcomes were compared between matched cohorts. Indirect costs included disability payments and medically related absenteeism. Drug costs were imputed with recent prices to account for availability of generic simvastatin. Among 4167 matched pairs of high-risk employees, atorvastatin use was associated with a numerically lower risk of CV events (17.6 versus 18.4%, P = 0.37), higher direct medical costs ($17,590 versus $17,377, P = 0.002), numerically lower indirect costs ($4830 versus $4989, P = 0.29), and higher total costs by $54 ($22,420 versus $22,366, P = 0.034). The majority of high-risk employees (62%) received low initial statin doses (atorvastatin = 10 mg or simvastatin = 20 mg). Among 9326 matched pairs of low- to intermediate-risk employees, atorvastatin use was associated with a lower risk of CV events (3.1% versus 3.7%, P = 0.030), lower direct medical costs ($8400 versus $8436, P < 0.001), numerically lower indirect costs ($2781 versus $2807; P = 0.12), and lower total costs by $61 ($11,181 versus $11,243, P < 0.001). These results suggest that formulary policies reserving atorvastatin for higher-risk patients may not be cost-saving from the employer perspective.

Comparing Medication Adherence Methods in Lipid-Modifying Therapy

Background:

Investigators have employed a number of different methods to calculate adherence estimates for patients taking lipid-modifying therapy (LMT), including measures with different numerator and denominator options. Although at least one method is known to correlate well with cardiovascular outcomes, most have not been evaluated in outcomes studies.

Objectives:

To evaluate different methods for measuring adherence, using LMT as a case example, and to determine whether estimates for adherence differ statistically and/or whether different methods can lead to different conclusions about patient adherence.

Methods:

Adherence ratios were calculated using 8 different methods for 12,448 patients who were in a managed-care system and were considered new starts with statin therapy. The calculated measures were compared and tested for differences. Patients were categorized as adherent by each method, using a threshold of 0.8, and the proportions of patients categorized as adherent were compared for differences between adherence calculation methods.

Results:

Adherence ratios calculated with like observation intervals did not vary substantially, regardless of which method for measuring medication availability was used. Those calculated with different observation intervals had substantial variability. Mean adherence ratios ranged between 0.777 and 0.798 for difference in days' observation intervals; they ranged between 0.618 and 0.630 for the predefined interval. Differences between ratios calculated using these different denominators were statistically significant (p < 0.008). Correlations between ratios were statistically significant for all comparisons (p < 0.001). Correlation coefficients ( r) were 0.64 for comparisons between ratios with different denominators versus 1.0 for comparisons with like denominators. Categorization as adherent or nonadherent differed between the methods for about 20% of patients.

Conclusions:

Significant differences were found to be based on observation period but not on medication availability. Studies of adherence should be interpreted with caution depending on which method is used, and particular interest should be paid to whether the choice of methods is consistent with study objectives and to the observation interval, as different methods may lead to different conclusions about patient adherence. Further research in LMT and other therapeutic areas is needed to determine which methods correlate best with positive patient outcomes, such as reductions in low-density lipoprotein cholesterol and cardiovascular events.

Antimigraine medication use and associated health care costs in employed patients

Migraine is under diagnosed and suboptimally treated in the majority of patients, and also associated with decreased productivity in employees. The objective of this retrospective study is to assess the antimigraine medication use and associated resource utilization in employed patients. Patients with primary diagnosis of migraine or receiving antimigraine prescription drugs were identified from an employer-sponsored health insurance plan in 2010. Medical utilization and health care costs were determined for the year of 2010. Generalized linear regression was applied to evaluate the association between health care costs and the use of antimigraine medications by controlling covariates. Of 465 patients meeting the study criteria, nearly 30% that had migraine diagnosis were prescribed antimigraine medications, and 20% that had migraine diagnosis were not prescribed antimigraine medications. The remaining 50% were prescribed antimigraine medications but did not have migraine diagnosis. Patients with antimigraine medication prescriptions showed lower frequency of emergency department visits than those without antimigraine medication prescriptions. Regression models indicated an increase in migraine-related health care costs by 86% but decreases in all-cause medical costs and total health care costs by 42 and 26%, respectively, in the antimigraine medication use group after adjusting for covariates. Employed patients experienced inadequate pharmacotherapy for migraine treatment. After controlling for covariates, antimigraine prescription drug use was associated with lower total medical utilization and health care costs. Further studies should investigate patient self-reported care and needs to manage headache and develop effective intervention to improve patient quality of life and productivity.