Drug Insight: statin use in the elderly

New therapies for primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is a rare inflammatory liver disease for which ursodeoxycholic acid (UDCA) is the only therapy approved by the U.S. Food and Drug Administration. Patients with a biochemical response to UDCA therapy have a similar survival rate compared to the general population. However, up to 40% of PBC patients do not achieve a complete response to UDCA, have an increased risk of liver-related death and liver transplantation, and represent a persistent medical need for new therapies. Several novel drugs have recently been studied and show potential efficacy in PBC. Obeticholic acid, a farnesoid X receptor agonist, has been tested in phase II trials and initial results after 1 year in a phase III international trial suggest that it may be effective in achieving a biochemical response in approximately 40% of patients who do not completely respond to UDCA. Several small studies on fibrates have suggested that they may have efficacy, but larger studies are needed. Surprisingly, results of immunomodulators and biologics have not yet been able to demonstrate efficacy, but new approaches have shown promise in animal models and their translation to human clinical trials are awaited.

Changes in cholesterol-lowering medications use over a decade in community-dwelling older adults

BACKGROUND

The impact of evidence-based guidelines and controlled trial data on use of cholesterol-lowering medications in older adults is unclear.

OBJECTIVE

To examine whether utilization patterns of cholesterol-lowering medications in community-dwelling older adults changed following the release of the National Cholesterol Education Program Adult Treatment Panel III guidelines and results from the Prospective Study of Pravastatin in the Elderly at Risk in 2002.

METHODS

Community-dwelling elderly individuals who were enrolled in the Health, Aging and Body Composition Study in 1997-1998 were followed for up to 11 years. An interrupted time series analysis with multivariable generalized estimating equations (GEEs) was used to examine changes in level and trend in cholesterol-lowering medication use before and after 2002, adjusting for sociodemographics, health-related behaviors, and health status.

RESULTS

Cholesterol-lowering medication use increased nearly 3-fold from 14.9% in 1997-1998 to 42.6% in 2007-2008, with statins representing the most common class used (87-94%). Multivariable GEE results revealed no significant difference in the level of cholesterol-lowering medication use after 2002 (adjusted OR 0.95; 95% CI 0.89-1.02). Multivariable GEE results revealed that trend changes in the rate of increase in cholesterol-lowering medication declined after 2002 (adjusted ratio of ORs 0.92; 95% CI 0.89-0.95).

CONCLUSIONS

The use of cholesterol-lowering medication increased substantially over a decade in community-dwelling elderly individuals but was not related to a change in level or trend following the release of the guidelines and evidence-based data.

Pharmacists' and pharmacy students' ability to identify drug-related problems using TIMER (Tool to Improve Medications in the Elderly via Review)

OBJECTIVE

Determine the effectiveness of TIMER (Tool to Improve Medications in the Elderly via Review) in helping pharmacists and pharmacy students identify drug-related problems during patient medication reviews.

METHODS

In a randomized, controlled study design, geriatric patient cases were sent to 136 pharmacists and 108 third-year pharmacy students who were asked to identify drug related-problems (DRPs) with and without using TIMER.

RESULTS

Pharmacists identified more tool-related DRPs using TIMER (p = 0.027). Pharmacy students identified more tool-related DRPs using TIMER in the first case (p = 0.02), but not in the second.

CONCLUSION

TIMER increased the number of DRPs identified by practicing pharmacists and pharmacy students during medication reviews of hypothetical patient cases.

Co-medication of statins and CYP3A4 inhibitors before and after introduction of new reimbursement policy

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

HMG-CoA reductase inhibitors (statins) are frequently used drugs in the treatment of dyslipidaemia. Co-medication with interacting drugs increases the risk of statin-induced muscular side-effects. Simvastatin exhibits particularly high interaction potential due to substantial metabolism via cytochrome P450 3A4 (CYP3A4).

WHAT THIS STUDY ADDS

In June 2005, a new reimbursement policy was introduced by the Norwegian Medicines Agency stating that simvastatin should be prescribed as first-line lipid-lowering therapy. Following introduction of the new policy, the number of patients co-medicated with simvastatin and CYP3A4 inhibitors almost doubled. A potential consequence is increased incidence of muscular side-effects in the statin-treated population.

AIMS

To assess the prevalence of co-medication of statins and CYP3A4 inhibitors before and after introduction of a new Norwegian reimbursement policy, which states that all patients should be prescribed simvastatin as first-line lipid-lowering therapy.

METHODS

Data from patients receiving simvastatin, lovastatin, pravastatin, fluvastatin or atorvastatin in 2004 and 2006, including co-medication of potent CYP3A4 inhibitors, were retrieved from the Norwegian Prescription Database covering the total population of Norway. Key measurements were prevalence of continuous statin use (two or more prescriptions on one statin) and proportions of different statin types among all patients and those co-medicated with CYP3A4 inhibitors.

RESULTS

In 2004, 5.9% (n= 272 342) of the Norwegian population received two or more prescriptions on one statin compared with 7.0% (n= 324 267) in 2006. The relative number of simvastatin users increased from 39.7% (n= 112 122) in 2004 to 63.1% (n= 226 672) in 2006. A parallel increase was observed within the subpopulation co-medicated with statins and CYP3A4 inhibitors, i.e. from 42.9% (n= 7706) in 2004 to 63.6% (n= 13 367) in 2006. For all other statins the number of overall users decreased to a similar extent to those co-medicated with CYP3A4 inhibitors.

CONCLUSIONS

In both 2004 and 2006, the choice of statin type did not depend on whether the patient used a CYP3A4 inhibitor or not. Considering the pronounced interaction potential of simvastatin with CYP3A4 inhibitors, a negative influence of the new policy on overall statin safety seems likely.

Management of dyslipidaemia in patients with type 2 diabetes in Australian primary care

OBJECTIVE

To examine the frequency of dyslipidaemia and treatment with lipid-lowering drugs in patients with type 2 diabetes managed in Australian primary care.

DESIGN, SETTING AND PARTICIPANTS

The NEFRON study (National Evaluation of the Frequency of Renal Impairment cO-existing with NIDDM [Non-Insulin Dependent Diabetes Mellitus]) was an incident-driven, cluster-stratified survey of 3893 patients with type 2 diabetes from across Australian primary care between April and September 2005.

MAIN OUTCOME MEASURES

The most recent fasting lipid levels were compared with therapeutic targets for lipid control and current prescribing guidelines.

RESULTS

64% of patients with type 2 diabetes presenting in primary care received lipid-lowering medication. Despite the widespread use of statins (61%), 75% of patients had a total cholesterol level >or= 4.0 mmol/L, and 47% had a low-density lipoprotein (LDL) cholesterol level >or= 2.5 mmol/L. Few untreated patients met the Australian Pharmaceutical Benefits Scheme (PBS) criteria current at the time for subsidised primary prevention with lipid-lowering agents (4%). However, new PBS subsidy criteria will potentially include 93% of all diabetic patients seeing their general practitioner in primary care.

CONCLUSION

Changes in the provision of subsidised therapy for high-risk diabetic patients are long overdue. However, more needs to be done to optimise management strategies, which still fail to achieve treatment targets in many treated patients.