Cholesterol Level Goal Attainment with Statins: Clinical Management Guideline Recommendations versus Management in Actual Clinical Practice

Association between adherence to statin therapy and low-density lipoprotein cholesterol (LDL-c) response in first-time users of standard-dose and low-dose statins: the PharmLines initiative

OBJECTIVE

To investigate whether statin adherence (defined as proportion days covered, PDC) is associated with LDL-c response in statin initiators on standard and low starting doses of statins, and to detect a possible interaction with sex.

METHODS

An inception cohort study was conducted using the PharmLines Initiative, a linkage between the Lifelines Cohort Study and the University of Groningen's IADB.nl (prescription database). First-time statin users were followed from baseline to follow-up measurement. We matched participants (1:1) between the standard-dose and the low-dose group of statin users on the duration of follow-up. Multiple linear regression analysis was used to model the association.

RESULTS

In univariate analysis, PDC was significantly associated with LDL-c response similarly (slope = -0.021), in both the standard-dose group (N = 115, p < .001) and the low-dose group (N = 115, p = .003). In the standard-dose group, the same level of PDC appeared to be significantly associated with a greater LDL-c level reduction in women (slope = -0.027, N = 48, p < .001) than in men (slope = -0.017, N = 67, p < .001). Meanwhile, in the low-dose group, the reduction of LDL-c level from baseline seemed to be greater in men (slope = -0.023, N = 56, p < .001) than in women (slope = -0.020, N = 59, p < .001) for the same level of PDC. In multiple regression analysis, the significant association between PDC and LDL-c with a similar pattern to the univariate result was maintained only in the standard-dose group.

CONCLUSIONS

Adherence is significantly associated with LDL-c response to statins at follow-up. Sex appears to significantly modify this association. At a similar adherence level, women seem to experience a better LDL-c response to standard-dose statins compared to men in a real-world setting.

COMPARISON OF REAL WORLD LIPID PROFILE OF PATIENTS WITH TYPE 2 DIABETES AND GUIDELINE RECOMMENDATIONS

Diabetes is a major risk factor for cardiovascular disease. Despite recommendations and available therapeutic options, patients with diabetes do not always reach the recommended lipid levels. In this study, our aim was to compare the real world lipid profile of type 2 diabetes patients with guideline recommendations for dyslipidemia. Four hundred and sixty eight consecutive patients referred to Outpatient Diabetes Clinic of Istanbul Medeniyet University were recruited. Patient anthropometric measurements (height, weight, waist circumference), biochemical test results (LDL cholesterol (LDL-c), triglycerides, HDL cholesterol, HbA1c) and treatment modalities were recorded. Patients were stratified into cardiovascular risk categories according to the risk factors and their treatment dose was compared to the recommendations. Among 468 patients, 56 (12%) patients had coronary heart disease (CHD). Thirty-four percent of these patients were not on statin treatment (n=19) and their mean LDL-c level was 114±29 mg/dL (2.9±0.75 mmol/L). Nineteen percent of these patients were on high intensity statin treatment (atorvastatin 40-80 mg, rosuvastatin 20 mg). Only four patients with CHD had LDL-c levels <70 mg/dL (1.8 mmol/L). Four hundred and twelve patients had no CHD. In these patients, the mean LDL-c level was 132±38 mg/dL (3.4±0.9 mmol/L). Eighty (19%) patients had LDL-c level lower than 100 mg/dL (2.5 mmol/L). Overall 82% (n=384) of the cohort had not achieved treatment goal. In conclusion, a more pronounced approach for statin treatment is needed in diabetes patients for both primary and secondary prevention of cardiovascular diseases.

The effects of tocotrienol supplementation on lipid profile: A meta-analysis of randomized controlled trials

BACKGROUND & OBJECTIVE

Tocotrienol supplementation has been emerged as a potent candidate for the treatment of dyslipidemia. In the present study, a systematic review and meta-analysis of randomized controlled trials was performed with the aim of examining the effects of tocotrienol supplementation on the lipid profile.

METHODS

Four databases (Scopus, PubMed/Medline, Web of Science and Embase) were used to accomplish the literature search up to November 2019. Clinical trials encompassing the impact of tocotrienol supplementation on lipid profile were extracted regardless of clinical condition, with studies included involving only adults patients.

RESULTS

A total of 15 articles with 20 arms were eligible and included in the meta-analysis to estimate the pooled effect size. Overall results showed a significant effect of tocotrienol supplementation on increasing high-density lipoprotein cholesterol (HDL-C) levels (weight mean difference (WMD): 0.146 mmol/L, I² = 85.9%) and a non-significant influence on total cholesterol (TC) (WMD: 0.010 mmol/L, I² = 64.5%), low-density lipoprotein cholesterol (LDL-C) (WMD: 0.095 mmol/L, I² = 87.4%), and triglycerides (TG) (WMD: -0.112 mmol/L, I² = 67.4%) levels. Increment in HDL-C levels was significant greater for the tocotrienol dosage ≥ 200 mg/d (WMD: 0.202 mmol/L) and ≤8 weeks (WMD: 0.278 mmol/L). Moreover, studies that investigated tocotrienol dose ≥200 mg had no heterogeneity, while showing a significant decrease in TG levels (WMD: -0.177 mmol/L).

CONCLUSION

The present meta-analysis demonstrated that supplementing with tocotrienols does not decrease the concentrations of LDL-C, TC and TG. However, tocotrienol supplementation was considered a candidate for increasing HDL-C levels.

Time trends analysis of statin prescription prevalence, therapy initiation, dose intensity, and utilization from the hospital information system of Jinshan Hospital, Shanghai (2012-2018)

BACKGROUND

Statin remains a mainstay in the prevention and treatment of cardiovascular diseases. Statin utilization has evolved over time in many countries, but data on this topic from China are quite limited. This study aimed to investigate the changing trends of statins prescription, as well as detail the statin utilization through a successive longitudinal study.

METHODS

The prescription database was established based on electronic health records retrieved from the hospital information system of Jinshan Hospital, Fudan University from January 2012 to December 2018 in Shanghai, China. The prescription rates and proportions of different statin types and doses among all patients were examined. Sub-analyses were performed when stratifying the patients by age, gender, dose intensity, and preventative intervention.

RESULTS

During the study period, a total of 51,083 patients, who were prescribed for statins, were included in this study (mean [SD] age, 59.78 [±13.16] years; 53.60% male, n = 27, 378). The overall statins prescription rate in which patients increased from 2012 (1.24, 95% CI: 1.21-1.27%) to 2018 (3.16, 95% CI: 3.11-3.20%), P < 0.001. Over 90% of patients were given a moderate dose of statins. Patients with a history of coronary and cerebrovascular events (over 32%) were more likely to be prescribed with statins for preventative intervention. Furthermore, our study has witnessed a significant rise in statin therapy in primary and secondary prevention.

CONCLUSIONS

In conclusion, statins were frequently prescribed and steadily increased over time in our study period. There were also changes in statin drug choices and dosages. A coordinated effort among the patient, clinical pharmacist, stakeholders and health system is still needed to improve statin utilization in clinical practice in the future.

Goat Milk Kefir Supplemented with Porang Glucomannan Improves Lipid Profile and Haematological Parameter in Rat Fed High Fat and High Fructose Diet

Background and Aims: Diet with a high fat and high sugar is associated with an increased incindence of the metabolic syndrome. Kefir has been known as a natural probiotic, while glucomannan from porang (Amorphophallus oncophyllus) tuber was demonstrated as prebiotic in vivo. Probiotics and prebiotics can be used adjuvant nutritional therapy for metabolic syndrome. The aim of this study was to evaluate the effect of goat milk kefir supplemented with porang glucomannan on the lipid profile and haematological parameters in rats fed with a high-fat/high-fructose (HFHF) diet.

Materials and methods: Rats were divided into 5 groups: normal diet; HFHF; HFHF + kefir; HFHF + kefir + glucomannan; and HFHF + simvastatin.

Results: There were significant differences before and after treatment in triglycerides and total cholesterol in HFHF + kefir+glucomannan group. The HFHF rats administered kefir with or without glucomannan had higher levels of lymphocytes and lower neutrophils compared to HFHF group (p<0.05). Only goat milk kefir without glucomannan proved to reduce platelets number.

Conclusion: Goat milk kefir supplemented with porang glucomannan could improve the health of rats fed high-fat/high-fructose, by decreasing plasma triglycerides, total cholesterol, and their immunomodulatory effect by decreasing number of neutrophils and increasing the lymphocytes. Especially for goat milk kefir had antithrombotic activity which important to prevent cardiovascular diseases.

Comparison of the efficacy and safety of intensive-dose and standard-dose statin treatment for stroke prevention: A meta-analysis

BACKGROUND

Previous study indicated that high-dose statin treatment might increase the risk of hemorrhagic stroke and adverse reactions. We aim to compare the efficacy and safety of intensive-dose and standard-dose statin treatment for preventing stroke in high-risk patients.

METHODS

A thorough search was performed of multiple databases for publications from 1990 to June 2015. We selected the randomized clinical trials comparing standard-dose statin with placebo and intensive-dose statin with standard-dose statin or placebo for the prevention of stroke events in patients. Duplicate independent data extraction and bias assessments were performed. Data were pooled using a fixed-effects model or a random-effects model if significant heterogeneity was present.

RESULTS

For the all stroke incidences, intensive-dose statin treatment compared with placebo treatment and standard-dose statin treatment compared with placebo treatment showed a significant 21% reduction in relative risk (RR) (RR 0.79, 95% confidence interval (CI) [0.71, 0.87], P < 0.00001) and an 18% reduction in RR (RR 0.82, 95% CI [0.73, 0.93], P = 0.002) in the subgroup without renal transplant recipients and patients undergoing regular hemodialysis separately. For the fatal stroke incidences, intensive-dose statin treatment compared with standard dose or placebo was effective reducing fatal stroke (RR 0.61, 95% CI [0.39, 0.96], P = 0.03) and the RR was 1.01 (95% CI [0.85, 1.20], P = 0.90) in standard-dose statin treatment compared with placebo.

CONCLUSION

The results of this meta-analysis suggest that intensive-dose statin treatment might be more favorable for reducing the incidences of all strokes than standard-dose statin treatment, especially for patients older than 65 years in reducing the incidences of all stroke incidences.

Prescribing patterns, adherence and LDL-cholesterol response of type 2 diabetes patients initiating statin on low-dose versus standard-dose treatment: a descriptive study

AIMS

The aim of this study was to describe and compare treatment modifications and discontinuation, adherence levels and response to treatment in patients with type 2 diabetes initiating on low-dose vs. standard-dose statin treatment.

METHODS

A 2-year follow-up cohort study was performed using data from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database in patients with type 2 diabetes initiating statin treatment between January 2007 and December 2012. First, we determined whether there were differences in treatment modifications and discontinuation after statin initiation between patients starting on a low-dose vs. standard-dose. Second, we looked at differences in adherence and LDL-cholesterol response after 2 years follow-up between these groups.

RESULTS

Around 22% of patients initiated statin treatment on a dose lower than recommended. More than half of them remained on a low dose during a 2-year follow-up period, whereas less than 15% received a dose increase. Of the patients initiating on standard-dose, also more than half remained on the same treatment during this period, whereas 8% received a dose decrease without subsequent increase. Over 25% of patients starting on low-dose or standard-dose treatment discontinued treatment, often within the first 180 days after initiation or after a first treatment change. Patients on low-dose treatment had lower adherence levels and were less likely to have adequate LDL-cholesterol response compared with patients on standard-dose after 2 years follow-up.

CONCLUSIONS

Current patterns of statin treatment in patients with type 2 diabetes are suboptimal, with discontinuation, inadequate adherence levels and lack of treatment intensification seen in those who had inadequate LDL-cholesterol response after 2 years of follow-up. Patients starting on low-dose had more treatment modifications, discontinuation and adherence problems as compared with those starting on standard-dose treatment, which calls for a closer look at the rationale of starting patients on low-dose statin treatment.

Adherence to standard-dose or low-dose statin treatment and low-density lipoprotein cholesterol response in type 2 diabetes patients

OBJECTIVE

To determine the association between adherence, dose and low-density lipoprotein (LDL) cholesterol response in patients with type 2 diabetes initiating statin treatment.

RESEARCH DESIGN AND METHODS

This cohort study was performed using data for 2007-2012 from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database. The association between adherence to a standard-dose statin and LDL cholesterol response was assessed using linear regression, adjusting for covariates. The effect of low-dose versus standard-dose was assessed in a propensity-score matched cohort. Adherence rates, defined as the proportion of days covered (PDC), were estimated between statin initiation and LDL outcome measurement.

MAIN OUTCOME MEASURE

LDL cholesterol level at follow-up.

RESULTS

The effect of adherence on LDL cholesterol response, measured in 2160 patients, was dependent on the baseline LDL cholesterol level. For patients with a baseline LDL cholesterol of 3.7 mmol/l and an adherence rate of 80%, a 40% reduction in LDL cholesterol was predicted. In the matched sample of 1144 patients, the treatment dose showed a difference in impact on the outcome for adherence rates higher than 50%. It was estimated that a patient with a baseline LDL cholesterol of 3.7 mmol/l will need an adherence rate of at least 76% on low-dose and 63% on standard-dose treatment to reach the LDL cholesterol target of 2.5 mmol/l.

LIMITATIONS

Adherence was measured as the PDC, which is known to overestimate actual adherence. Also, we were not able to adjust for lifestyle factors.

CONCLUSIONS

We determined the concurrent effect of treatment adherence and dose on LDL cholesterol outcomes. Given the adherence levels seen in clinical practice, diabetes patients initiating statin treatment are at high risk of not reaching the recommended cholesterol target, especially when they start on a low-dose statin.

Efficacy of standard and intensive statin treatment for the secondary prevention of cardiovascular and cerebrovascular events in diabetes patients: a meta-analysis

Aims

To estimate the efficacy of standard and intensive statin treatment in the secondary prevention of major cardiovascular and cerebrovascular events in diabetes patients.

Methods

A systematic search was conducted in Medline over the years 1990 to September 2013. Randomized, double-blind, clinical trials comparing a standard-dose statin with placebo or a standard-dose statin with an intensive-dose statin for the secondary prevention of cardiovascular and cerebrovascular events in diabetes patients were selected. Trial and patient characteristics were extracted independently by two researchers. The combined effect on the composite primary endpoint was measured with a fixed-effect model. Potential publication bias was examined with a funnel plot.

Results

Five trials were included in the analysis comparing standard-dose statins with placebo with a total of 4 351 participants. Four trials were included for comparing standard-dose with intensive-dose statins, including 4 805 participants. Compared with placebo, standard-dose statin treatment resulted in a significant relative risk (RR) reduction of 15% in the occurrence of any major cardiovascular or cerebrovascular event (RR 0.85, 95% CI 0.79–0.91). Compared with standard-dose statin treatment, intensive-dose statin treatment resulted in an additional 9% relative risk reduction (RR 0.91, 95% CI 0.84–0.98).

Conclusion

Treatment with standard-dose statins to prevent cardiovascular or cerebrovascular events in diabetes patients with manifest cardiovascular disease results in an estimated 15% relative risk reduction and intensive-dose statin treatment adds 9%. If proven cost-effective, more intensive statin treatment should be recommended for diabetes patients at high cardiovascular risk.