Key aspects of statin intolerance leading to treatment discontinuation: a patient perspective

Background and aims

Statins are the standard of care for patients with dyslipidemia, but some patients develop intolerance to treatment. The experience of statin intolerant (SI) patients is poorly understood. The objective of this study was to identify key aspects of SI that may be associated with treatment discontinuation.

Methods

Using a previously created questionnaire, we conducted a pilot cross-sectional survey to identify items important for describing patient-centric aspects of SI. The study recruited adult (18+) patients with a history of statin-associated side effects from 9 clinics in 6 countries (France, Italy, Norway, Spain, Sweden, and the United Kingdom), who had received statin treatment within the previous two years.

Results

We surveyed 104 patients (mean age 61.5 SD=11.2 years, 63.5% men, 50% currently on statins). Patients most frequently reported muscle-related symptoms: pain (90.9%), cramps (63.7%), and stiffness (58.2%). Using a 0–10 point scale, significant differences were found between those continuing versus discontinuing their statins for being bothered by side effects (7.5 vs 9.2, p=0.001), for an inability to tolerate side effects (6.7 vs 9.0, p<0.001), and those having too much side effects interference with their daily life (5.7 vs 8.6, p<0.001; see figure). For patients whose doctors worked on adjusting statin regimen, 67% stayed on treatment; for those whose doctors did not, only 10% continued treatment.

Conclusions

Results of this pilot survey suggest patients who experience greater side effects severity and interference with daily activity, along with lower efforts by clinicians to work with adjusting their statin regimen, are at greater risk for discontinuing treatment. A wider survey and larger study population is needed to confirm the results of this pilot study.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was sponsored by Amgen Inc.

A longitudinal evaluation of cardiovascular risk factors, treatment patterns, and outcomes in patients with documented cardiovascular disease treated with lipid lowering therapy in the United Kingdom

Background

Over time, guidelines for dyslipidemia management in patients at high risk of atherosclerotic cardiovascular disease (CVD) changed with the goal of improving patient outcomes. Guidelines have been released by the European Joint Task Force in 2007, 2012 and 2016, European Society of Cardiology in 2011, 2016 and 2019, Joint British Societies in 2014, and National Institute for Health and Care Excellence in 2014.

Purpose

Evaluate cardiovascular risk factors, treatment patterns, and cardiovascular outcomes over time related to dyslipidemia management.

Methods

Ten prevalent cohorts of patients with documented CVD receiving lipid-lowering therapy (LLT) were created using Clinical Research Practice Datalink (CPRD) records as of January 1, each year from 2008 through 2017. For each cohort, we identified CVD risk factors and LLT, and estimated the 1-year composite rate of fatal and nonfatal myocardial infarction (MI), ischemic stroke (IS), or revascularization. Patient follow-up was censored at the earliest of one year, end of data, or the outcome of interest. Patients in each cohort were required to be ≥18 years old, have ≥1 years of available medical history, and have received ≥2 LLT prescriptions in the prior year. Documented CVD was defined as MI, IS, angina, revascularization, transient ischemic attack, carotid stenosis, abdominal aortic aneurysm, or peripheral arterial disease. Patients could be in multiple cohorts.

Results

Annual patient counts ranged from 170,501 to 179,137 through 2013 and declined to 94,418 by 2017 (due to fewer patients in the overall CPRD data). Comparing 2008, 2011 (when ESC guidelines were revised) and 2017 showed the following for CVD risk factors: mean age was 71.6, 72.3, and 72.5 years; males were 59.9%, 61.1%, and 63.1%; current smoking was 15.1%, 15.2%, and 13.9%; type 2 diabetes was 18.4%, 20.2%, and 22.4%; stage 3–5 chronic kidney disease was 22.4%, 25.1%, and 22.8%; history of MI was 22.5%, 23.9%, and 27.4%; history of IS was 5.5%, 6.6%, and 7.9%; LDL <1.8 mmol/L was 27.8%, 29.2% and 37.2%; and LDL <1.4 mmol/L was 9.9%, 10.1%, and 15.6%. In terms of treatment, high intensity statin use increased from 12.9% to 15.7% to 30.8%; atorvastatin 40–80 mg use increased from 12.9% to 15.5% to 30.5%; while simvastatin 20–40 mg use decreased from 55.4% to 58.8% to 36.7%. The 1-year cardiovascular event rate declined from 2.54 to 2.35 to 1.96 events per 100 person-years (Figure).

Conclusions

After 2011 in the UK, there was an increased use of high intensity statins, a greater proportion of patients with LDL levels <1.8 and <1.4 mmol/L, and lower 1-year cardiovascular event rates. While improved CVD management likely contributed to the event rate decline, less than 40% of very high-risk patients achieved an LDL <1.8 mmol/L, and the proportion with LDL <1.4 mmol/L, as recommended by the 2019 ESC guidelines, was less than 20%. Clinicians should continue their efforts to reduce LDL in these patients.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Amgen

P643Association of adherence and treatment intensity of lipid-lowering therapy with cardiovascular outcomes and all-cause mortality in very high-risk patients in Germany

Introduction

Both intensity and adherence to lipid lowering therapies (LLT) play an important role in effectiveness of the therapies in patients at risk for cardiovascular events.

Purpose

To evaluate the association of adherence and treatment intensity with cardiovascular outcomes and all-cause mortality in very high-risk patients (as defined by the current ESC guidelines) treated with statin and/or ezetimibe.

Methods

Retrospective cohort study was based on German health claims data (2010–2015) obtained from German Institute for Health Research (InGef) database and included patients ≥18 years with an initial LLT treatment (statin and/or ezetimibe) in 2011–2013, and diagnoses of cardiovascular disease (CVD), stage 4 or 5 chronic kidney disease (CKD) or type 2 diabetes mellitus (DM). Patients must have had at least 2 LLT prescriptions in the first year to ensure intention of treatment. Follow-up period started 1 year after the second LLT prescription and continued until one of the events of the composite study endpoint (hospitalisation for myocardial infarction, unstable angina, ischemic stroke, heart failure, revascularization, or all-cause death) or 31.12.2015, whichever occurred earlier. Adherence was measured annually by the proportion of days covered (PDC) using prescription data. Treatment intensity was quantified based on expected LDL-C reduction as described in the American College of Cardiology and American Heart Association (ACC/AHA) 2018 guidelines. Adherence and treatment intensity were multiplied to create a combined measure of intensity after accounting for adherence.

Results

73,257 patients of the CVD cohort were 68 (SD=12) years old, 59% men; the DM cohort (no CVD) had 13,584 patients, age 64 (10), 47% men; 472 patients in the CKD cohort (no CVD) were 65 (15) years old, 46% men. In a Cox proportional hazards model, each 10% increase in treatment intensity (LDL-C lowering) was associated with 18% lower risk of CV event in the CVD (HR 0.82, 95% CI 0.82–0.83), 21% - in the DM (HR 0.79, 95% CI 0.76–0.83), and 15% - in the CKD (HR 0.85, 95% CI 0.75–0.97) cohorts. Similarly, each 10% increase in adherence (PDC) was associated with 6% lower risk of CV event in the CVD (HR 0.94, 95% CI 0.93–0.94), 7% - in the DM (HR 0.93, 95% CI 0.91–0.94), and 7% - in the CKD (HR 0.93, 95% CI 0.89–0.97) cohorts. Each 10% increase in adherence-adjusted intensity was associated with 16% lower risk of CV event in the CVD (HR 0.84, 95% CI 0.83 - 0.85), 19% - in the DM (HR 0.81, 95% CI 0.78–0.85), and 17% - in the CKD (HR 0.83, 95% CI 0.72–0.96) cohorts. The models controlled for age, sex, Charlson comorbidity index and other cardiovascular risk factors at baseline.

Conclusions

A higher adherence and/or treatment intensity of LLT was associated with significantly lower risk of CV outcomes or all-cause death in German very high-risk patients. Strategies to tailor intensity to patient profile and improve adherence could further lower risk of CV events.

Acknowledgement/Funding

Amgen Europe GmbH

Calcifediol versus vitamin D3 effects on gait speed and trunk sway in young postmenopausal women: a double-blind randomized controlled trial

In this double-blind RCT, 4-month treatment with calcifediol compared with vitamin D3 improved gait speed by 18% among young postmenopausal women. Consistently, change in 25(OH)D blood levels over time were significantly correlated with improvement in gait speed in these women. No effect could be demonstrated for trunk sway.

INTRODUCTION

The aim of this study is to test the effect of calcifediol compared with vitamin D3 on gait speed and trunk sway.

METHODS

Twenty healthy postmenopausal women with an average 25(OH)D level of 13.2 ng/ml (SD = ±3.9) and a mean age of 61.5 years (SD = ±7.2) were randomized to either 20 μg of calcifediol or 20 μg (800 IU) of vitamin D3 per day in a double-blind manner. At baseline and at 4 months of follow-up, the same physiotherapist blinded to treatment allocation tested 8-m gait speed and a body sway test battery (Sway star pitch and roll angle plus velocity while walking 8 m, and standing on both legs on a hard and soft surface). All analyses adjusted for baseline measurement, age, and body mass index.

RESULTS

Mean 25(OH)D levels increased to 69.3 ng/ml (SD = ±9.5) in the calcifediol group and to 30.5 ng/ml (SD = ±5.0) in the vitamin D3 group (p < 0.0001). Women receiving calcifediol compared with vitamin D3 had an 18% greater improvement in gait speed at 4-month follow-up (p = 0.046) adjusting for baseline gait speed, age, and body mass index. Also, change in gait speed was significantly correlated with change in serum 25(OH)D concentrations (r = 0.5; p = 0.04). Across three tests of trunk sway, there were no consistent differences between groups and no significant correlation between change in 25(OH)D serum concentrations and change in trunk sway.

CONCLUSIONS

Calcifediol improved gait speed in early postmenopausal women compared with vitamin D3 and change in 25(OH)D level was moderately correlated with improvement in gait speed. A benefit on trunk sway could not be demonstrated.

Gender-specific hip fracture risk in community-dwelling and institutionalized seniors age 65 years and older

In this study of acute hip fracture patients, we show that hip fracture rates differ by gender between community-dwelling seniors and seniors residing in nursing homes. While women have a significantly higher rate of hip fracture among the community-dwelling seniors, men have a significantly higher rate among nursing home residents.

INTRODUCTION

Differences in gender-specific hip fracture risk between community-dwelling and institutionalized seniors have not been well established, and seasonality of hip fracture risk has been controversial.

METHODS

We analyzed detailed data from 1,084 hip fracture patients age 65 years and older admitted to one large hospital center in Zurich, Switzerland. In a sensitivity analysis, we extend to de-personalized data from 1,265 hip fracture patients from the other two large hospital centers in Zurich within the same time frame (total n = 2,349). The denominators were person-times accumulated by the Zurich population in the corresponding age/gender/type of dwelling stratum in each calendar season for the period of the study.

RESULTS

In the primary analysis of 1,084 hip fracture patients (mean age 85.1 years; 78% women): Among community-dwelling seniors, the risk of hip fracture was twofold higher among women compared with men (RR = 2.16; 95% CI, 1.74-2.69) independent of age, season, number of comorbidities, and cognitive function; among institutionalized seniors, the risk of hip fracture was 26% lower among women compared with men (RR = 0.77; 95% CI: 0.63-0.95) adjusting for the same confounders. In the sensitivity analysis of 2,349 hip fracture patients (mean age 85.0 years, 76% women), this pattern remained largely unchanged. There is no seasonal swing in hip fracture incidence.

CONCLUSION

We confirm for seniors living in the community that women have a higher risk of hip fracture than men. However, among institutionalized seniors, men are at higher risk for hip fracture.

Before and after hip fracture, vitamin D deficiency may not be treated sufficiently

Our findings show that only about 20% of seniors receive vitamin D supplementation prior to their index hip fracture or after the event. We further confirm the high prevalence of severe vitamin D deficiency in this population and show that those who receive supplementation have significantly higher 25-hydroxyvitamin D (25(OH)D) status.

INTRODUCTION

The aim of this study is to assess current practice in pre- and post-hip fracture care practice with respect to vitamin D supplementation.

METHODS

We surveyed 1,090 acute hip fracture patients age 65 and older admitted to acute care for hip fracture repair; 844 had serum 25-hydroxyvitamin D levels measured upon admission to acute care, and 362 agreed to be followed at 12 month after their hip fracture. Prevalence of vitamin D supplementation was assessed upon admission to acute care (at the time of hip fracture), upon discharge from acute care, and at 6 and 12 months follow-up.

RESULTS

Of 1,090 acute hip fracture patients (mean age 85 years, 78% women, 59 % community-dwelling), 19% had received any dose of vitamin D prior to the index hip fracture, 27% (of 854 assessed) at discharge from acute care, 22 % (of 321 assessed) at 6 month, and 21% (of 285 assessed) at 12 month after their hip fracture. At the time of fracture, 45% had 25(OH)D levels below 10 ng/ml, 81% had levels below 20 ng/ml, and 96% had levels below 30 ng/ml. Notably, 25(OH)D levels did not differ by season or gender but were significantly higher among 164 hip fracture patients, with any vitamin D supplementation compared with 680 without supplementation (19.9 versus 10.8 ng/ml; p < 0.0001).

CONCLUSION

Only about 20% of seniors receive vitamin D at the time of their fracture and after the event. This is despite the documented 81% prevalence of vitamin D deficiency. Interdisciplinary efforts may be warranted to improve vitamin D supplementation in seniors both before a hip fracture occurs and after.

Mild to moderate cognitive impairment is a major risk factor for mortality and nursing home admission in the first year after hip fracture

BACKGROUND

It is not well established if and to what extent mild to moderate cognitive impairment predicts mortality and risk of nursing home admission after hip fracture.

OBJECTIVE

To investigate prospectively whether and to what extent mild to moderate cognitive impairment, contributes to mortality and admission to nursing home in the first year after acute hip fracture.

METHODS

We enrolled 173 patients with acute hip fracture age 65 and older who reached a Mini-Mental State Examination (MMSE) score of at least 15 during acute care after hip fracture repair. An MMSE score of 15 to 24 (median) was classified as mild to moderate cognitive impairment. Primary outcomes were mortality in all and admission to nursing home among seniors who lived at home prior to their hip fracture. Follow-up was 12 months with clinical visits at baseline, 6, and 12 months, plus monthly phone calls. We used Cox proportional hazards models controlling for age, sex, body mass index, baseline number of comorbidities and 25-hydroxyvitamin D status, and severe incident infections to assess the risk of mortality and nursing home admission. Because the study population was enrolled in a factorial design clinical trial testing high dose vitamin D and/or an exercise home program, all analyses also controlled for these treatment strategies.

RESULTS

Of 173 acute hip fracture patients enrolled, 79% were women, 77% were admitted from home, and 80% were vitamin D deficient (<20ng/ml). Mean age was 84 years. 54% had mild to moderate cognitive impairment. Over the 12-month follow-up, 20 patients died (27% of 173) and 47 (35% of 134) were newly admitted to a nursing home. Mild to moderate cognitive impairment was associated with a more than 5-fold increased risk of mortality (HR=5.77; 95% CI: 1.55-21.55) and a more than 7-fold increased risk of nursing home admission (HR=7.37; 95% CI: 1.75-30.95). Additional independent risk factors of mortality were male gender (HR=3.55; 95% CI: 1.26-9.97), low BMI (HR=7.25; 95% CI: 1.61-33.74), and baseline 25-hydroxyvitamin D level (per 1ng/ml: HR=0.93; 95% CI: 0.87-0.998; p=0.04).

CONCLUSIONS

Mild to moderate cognitive impairment in patients with acute hip fracture is associated with a high risk of mortality and nursing home admission during the first year after hip fracture. Female gender, a greater BMI and a higher 25-hydroxyvitamin D status may protect against mortality after hip fracture independent of cognitive function.