Predictors of first-year nonadherence and discontinuation of statins among older adults: a retrospective cohort study

Trend of the lipid profile in a cohort with severe hypercholesterolemia in Osona county (Barcelona, Spain), between 2009 and 2021

BACKGROUND

Various studies confirm that the prevalence of dyslipidemia and other cardiovascular factors is high.

OBJECTIVE

To evaluate the trend of the lipid profile (LP) in a cohort with severe hypercholesterolemia and its relationship with lipid-lowering treatment during the period 2009-2021.

METHODS

Cross-sectional study carried out in the Osona county (Barcelona). Outpatients from the first period (2009-2011) who were aged between 25 and 65 years and had severe hypercholesterolemia were selected (n = 2,608). In a second period (2019-2021), these patients (n = 1,855) were followed up to evaluate the trend of LP and its relationship with lipid-lowering treatment. The Student's T-test (paired data) was used to identify differences between observations from the two periods.

RESULTS

Lipid-lowering treatment was prescribed to 61.9% of patients. The group of patients of the cohort improved the data of the mean results of the LP. Approximately 75% of cases were unable to establish their cholesterol and atherogenic fraction values. The prescription of lipid-lowering treatment in the cardiovascular disease group (CVD) was 80.9% vs 61.9% of the total cohort.

CONCLUSION

Three out of four cases failed to reduce the levels of LDL-C and non-HDL-C, recommended by the guidelines of scientific societies. Primary Care is the ideal framework to implement improvement strategies to control severe hypercholesterolemia, and it is therefore essential to strengthen it.

Impact of Interventions on Medication Adherence in Patients With Coexisting Diabetes and Hypertension

BACKGROUND

The coexistence of diabetes and hypertension is prevalent due to shared risk factors. Pharmacological treatment has been reported to be effective in managing both conditions. However, treatment effectiveness depends on the extent to which a patient adheres to their treatment. Poor adherence to long-term treatment for chronic diseases is a growing global problem of significant magnitude. Several interventions have been developed to help improve medication adherence in patients with coexisting diabetes and hypertension. This review aimed to determine the characteristics of these interventions and their impact on medication adherence.

METHODS

A systematic review of the literature was conducted using the PRISMA guidelines and registered in the PROSPERO International Registry of Systematic Reviews. Studies were searched in the databases CINAHL, Embase and Medline to identify relevant articles published during 2012-2023. The search concepts included 'medication adherence', 'hypertension', 'diabetes' and 'intervention'. Studies were included if they were in English and evaluated the impact of an intervention aimed at promoting adherence to medications for both diabetes and hypertension.

RESULTS

Seven studies met the inclusion criteria, with five demonstrating a statistically significant improvement in medication adherence. Of the five studies that improved medication adherence, four were multifaceted and one was a single-component intervention. All successful interventions addressed at least two factors influencing non-adherence. Patient education was the foundation of most of the successful interventions, supported by other strategies, such as follow-ups and reminders.

CONCLUSION

Multifaceted interventions that also included patient education had a positive impact on medication adherence in patients with coexisting diabetes and hypertension. Improving adherence in patients with coexisting diabetes and hypertension requires a multipronged approach that considers the range of factors impacting medication-taking.

PATIENT OR PUBLIC CONTRIBUTION

This systematic review provides comprehensive insights into the benefits of patient-centred approaches in intervention development and strengthening. Such patient involvement ensures that medication adherence interventions are more relevant, acceptable and effective, ultimately leading to better health outcomes and more meaningful patient engagement in healthcare research.

Initiation of lipid-lowering therapy as primary prevention of cardiovascular disease in the elderly

AIMS

This study aimed to analyse the initiation adherence phase to lipid-lowering therapy for primary prevention of cardiovascular disease in a Spanish population aged 70 years or older. The secondary objective was to identify the determinants of initiation and early discontinuation.

METHODS

This was an observational study conducted in the CArdiovascular Risk factors for HEalth Service research (CARhES) cohort. People aged 70 and older with a first prescription of a lipid-lowering drug and without a previous major adverse cardiovascular event (MACE) were selected (2018-2021). Data on sociodemographics, clinical conditions, drugs and use of health services were collected from clinical and administrative electronic databases. The study population was classified into: non-initiation, early discontinuation (i.e., discontinuation after the first dispensing) and initiation with more than one dispensing. Their characteristics were compared. Determinants of initiation and early discontinuation were explored.

RESULTS

Among the 15 019 people studied, 80.2% initiated the medication, 11.2% showed an early discontinuation and 8.6% were non-initiators. An older age or conditions such as dementia, diabetes or depression reduced the likelihood of initiation, while obesity and a high pharmacological burden increased it. People over 90 years of age or those prescribed a statin in combination were more likely to have an early discontinuation.

CONCLUSIONS

Non-initiation and early discontinuation are common among older people prescribed lipid-lowering drugs as primary prevention of cardiovascular disease for the first time. The presence of chronic pathologies other than cardiovascular ones should be considered when assessing whether or not to prescribe these drugs in the elderly.

Cholesterol Lowering in Older Adults: Should We Wait for Further Evidence?

PURPOSE OF REVIEW

Current guidelines for primary and secondary prevention of cardiovascular events in adults up to age 75 years are well-established. However, recommendations for lipid-lowering therapies (LLT), particularly for primary prevention, are inconclusive after age 75. In this review, we focus on adults ≥ 75 years to assess low-density lipoprotein-cholesterol (LDL-C) as a marker for predicting atherosclerotic cardiovascular disease (ASCVD) risk, review risk assessment tools, highlight guidelines for LLT, and discuss benefits, risks, and deprescribing strategies.

RECENT FINDINGS

The relationship between LDL-C and all-cause mortality and cardiovascular outcomes in older adults is complex and confounded. Current ASCVD risk estimators heavily depend on age and lack geriatric-specific variables. Emerging tools may reclassify individuals based on biologic rather than chronologic age, with coronary artery calcium scores gaining popularity. After initiating LLT for primary or secondary prevention, target LDL-C levels for older adults are lacking, and non-statin therapy thresholds remain unknown, relying on evidence from younger populations. Shared decision-making is crucial, considering therapy's time to benefit, life expectancy, adverse events, and geriatric syndromes. Deprescribing is recommended in end-of-life care but remains unclear in fit or frail older adults. After an ASCVD event, LLT is appropriate for most older adults, and deprescribing can be considered for those approaching the last months of life. Ongoing trials will guide statin prescription and deprescribing among older adults free of ASCVD. In the interim, for adults ≥ 75 years without a limited life expectancy who are free of ASCVD, an LLT approach that includes both lifestyle and medications, specifically statins, may be considered after shared decision-making.

Prevalence, Associated Risk Factors, and Adverse Cardiovascular Outcomes of Statins Discontinuation: A Systematic Review

PURPOSE

Statins are widely prescribed for cardiovascular diseases (CVD) prevention; however, a significant proportion of users discontinue the medication for various reasons. This review aimed to determine the prevalence of statin therapy discontinuation, its associated factors, and adverse cardiovascular outcomes within the first year of discontinuation.

METHODS

The PubMed, EMBASE, ScienceDirect, SCOPUS, and Google Scholar databases were systematically searched from their inception to December 2022. Manual searches were also conducted on the bibliographies of relevant articles. Studies were included for qualitative data synthesis and assessed for methodological quality.

RESULTS

Fifty-two studies, predominantly cohort studies (n = 38), involving 4 277 061 participants were included. The prevalence of statin discontinuation within the first year of statin initiation ranged from 0.8% to 70.5%, which was higher for primary prevention indications. Factors frequently associated with an increased likelihood of statin discontinuation included male sex, nonWhite ethnicity, smoking status, and being uninsured. Conversely, discontinuation was less likely in patients with CVD who received secondary prevention statin therapy and in patients with polypharmacy. Furthermore, age showed diverse and inconsistent relationships with statin discontinuation among various age categories. Five studies that reported the cardiovascular risk of statin discontinuation within the first year of initiation showed significantly increased risk of discontinuation, including all-cause mortality (hazard ratio: 1.36-3.65).

CONCLUSION

Our findings indicate a high prevalence of statin discontinuation and an increased likelihood of adverse cardiovascular outcomes within the first year of discontinuation, despite wide variability across published studies. This review highlights the importance of addressing the modifiable risk factors associated with statin discontinuation, such as smoking and lack of insurance coverage.

Statins use amidst the pandemic: prescribing, dispensing, adherence, persistence, and correlation with COVID-19 statistics in nationwide real-world data from Poland

Background

Adherence to medications presents a significant challenge in healthcare. Statins, used in primary and secondary prevention of cardiovascular disease, are of particular importance for public health. The outbreak of the COVID-19 pandemic resulted in additional healthcare system-related barriers impeding the execution of therapies. This study aimed to assess the use of as well as adherence and persistence to statins in a national cohort of 38 million of Polish citizens during pandemic.

Methods

A retrospective analysis of prescription and dispensation data for all statins users from the national payer organization covering the years 2020-2022 was conducted. Medication adherence was assessed using the Medication Possession Ratio, for persistence the 30-day cut-off was accepted. National data on COVID-19 cases and COVID-19 related deaths were obtained from ECDC.

Results

The analysis identified 7,189,716 Polish citizens (approximately 19% of Polish population) who were dispensed at least 1 pack of statins within the study period. Over that time, there was a continuous significant increasing trend in prescribing and dispensing of statins. Despite a total increase of 18.9% in the number of prescribed tablets, the percentage of tablets dispensed remained similar, averaging 86%. Overall percentage of adherent patients was 48.2%. For a random sample of 100,000 patients, the mean period of continuous therapy in 2022 was 6.2+/- 5.3 months. During the lockdown period, the mean number of prescribed and dispensed tablets was lower by 6.8% and 5.9%, respectively (p < 0.05). However, fluctuations in the number of COVID-19 cases or COVID-19-related deaths per week had no major impact on the prescribing and dispensing of statins.

Conclusion

Over the time of pandemic, there was a continuous increase in the number of statin tablets prescribed and dispensed in Poland. This suggests that, despite the potential limitations posed by COVID-19, access to statins remained easy, which may be attributed to the mass-scale implementation of the national e-prescription system. However, it is crucial to realise that approximately 1/7 of prescribed statin doses were never dispensed, and the overall levels of adherence and persistence were low. This underscores the necessity for concerted efforts to change this scenario in Poland.

Trajectories of oral bisphosphonate use after hip fractures: a population-based cohort study

Bisphosphonates prevent future hip fractures. However, we found that one in six patients with hip fractures had a delay in bisphosphonate initiation and another one-sixth discontinued treatment within 12 months after discharge. Our results highlight the need to address hesitancy in treatment initiation and continuous monitoring.

PURPOSE

Suboptimal antiresorptive use is not well understood. This study investigated trajectories of oral bisphosphonate use following first hip fractures and factors associated with different adherence and persistence trajectories.

METHODS

We conducted a retrospective study of all patients aged ≥ 50 years dispensed two or more bisphosphonate prescriptions following first hip fracture in Victoria, Australia, from 2012 to 2017. Twelve-month trajectories of bisphosphonate use were categorized using group-based trajectory modeling. Factors associated with different trajectories compared to the persistent adherence trajectory were assessed using multivariate multinomial logistic regression.

RESULTS

We identified four patterns of oral bisphosphonate use in 1811 patients: persistent adherence (66%); delayed dispensing (17%); early discontinuation (9%); and late discontinuation (9%). Pre-admission bisphosphonate use was associated with a lower risk of delayed dispensing in both sexes (relative risk [RR] 0.28, 95% confidence interval [CI] 0.21-0.39). Older patients ( ≥ 85 years old versus 50-64 years old, RR 0.38, 95% CI 0.22-0.64) had a lower risk of delayed dispensing. Males with anxiety (RR 9.80, 95% CI 2.24-42.9) and females with previous falls had increased risk of early discontinuation (RR 1.80, 95% CI 1.16-2.78).

CONCLUSION

Two-thirds of patients demonstrated good adherence to oral bisphosphonates over 12 months following hip fracture. Efforts to further increase post-discharge antiresorptive use should be sex-specific and address possible persistent uncertainty around delaying treatment initiation.

World Heart Federation Roadmap for Secondary Prevention of Cardiovascular Disease: 2023 Update

Background

Secondary prevention lifestyle and pharmacological treatment of atherosclerotic cardiovascular disease (ASCVD) reduce a high proportion of recurrent events and mortality. However, significant gaps exist between guideline recommendations and usual clinical practice.

Objectives

Describe the state of the art, the roadblocks, and successful strategies to overcome them in ASCVD secondary prevention management.

Methods

A writing group reviewed guidelines and research papers and received inputs from an international committee composed of cardiovascular prevention and health systems experts about the article's structure, content, and draft. Finally, an external expert group reviewed the paper.

Results

Smoking cessation, physical activity, diet and weight management, antiplatelets, statins, beta-blockers, renin-angiotensin-aldosterone system inhibitors, and cardiac rehabilitation reduce events and mortality. Potential roadblocks may occur at the individual, healthcare provider, and health system levels and include lack of access to healthcare and medicines, clinical inertia, lack of primary care infrastructure or built environments that support preventive cardiovascular health behaviours. Possible solutions include improving health literacy, self-management strategies, national policies to improve lifestyle and access to secondary prevention medication (including fix-dose combination therapy), implementing rehabilitation programs, and incorporating digital health interventions. Digital tools are being examined in a range of settings from enhancing self-management, risk factor control, and cardiac rehab.

Conclusions

Effective strategies for secondary prevention management exist, but there are barriers to their implementation. WHF roadmaps can facilitate the development of a strategic plan to identify and implement local and national level approaches for improving secondary prevention.

Clinical Characteristics of Patients With Statin Discontinuation in Korea: A Nationwide Population-Based Study

Objective

To investigate the clinical characteristics of patients with statin discontinuation in Korea, using a nationwide database.

Methods

We analyzed 1,308,390 patients treated with statin for the first time in their life between 2016 and 2017 using the Korean National Health Information Database. The patients participated in the Korean National Health Screening Program within two years before taking statin. Patients with statin discontinuation were defined as those who were not prescribed statin between 365 days and 730 days after the initial statin prescription.

Results

The overall prevalence of statin discontinuation was 39.44%. Patients with statin discontinuation were younger, had lower body mass index (BMI), included a higher number of smokers and drinkers, did not exercise regularly, with fewer cases of hypertension and diabetes mellitus than those without statin discontinuation (p<0.001). Compared with patients aged 20-29 years, the risk of statin discontinuation showed a U-shaped relationship with age (odds ratios [ORs]: 0.619 in 30-39 years; 0.454 in 40-49 years; 0.345 in 50-59 years; 0.307 in 60-69 years; 0.324 in 70-79 years; and 0.415 in ≥80 years). In addition, increased BMI was associated with decreased risk of statin discontinuation (ORs: 0.969 with 25.0-29.9 kg/m2, and 0.890 with ≥30.0 kg/m2). Patients with hypertension and diabetes mellitus were at a lower risk of statin discontinuation (OR: 0.414 for hypertension; 0.416 for diabetes mellitus).

Conclusion

The prevalence of patients with statin discontinuation in Korea was 39.44% at 1 to 2 years after initial statin treatment.

A mobile health application for patients eligible for statin therapy: app development and qualitative feedback on design and usability

BACKGROUND

Cardiovascular disease is the leading cause of death in the United States (US). Despite the well-recognized efficacy of statins, statin discontinuation rates remain high. Statin intolerance is a major cause of statin discontinuation. To accurately diagnose statin intolerance, healthcare professionals must distinguish between statin-associated and non-statin-associated muscle symptoms, because many muscle symptoms can be unrelated to statin therapy. Patients' feedback on muscle-related symptoms would help providers make decisions about statin treatment. Given the potential benefits and feasibility of existing apps for cardiovascular disease (CVD) management and the unmet need for an app specifically addressing statin intolerance management, the objectives of the study were 1) to describe the developmental process of a novel app designed for patients who are eligible for statin therapy to lower the risk of CVD; 2) to explore healthcare providers' feedback of the app; and 3) to explore patients' app usage experience.

METHODS

The app was developed by an interdisciplinary team. Healthcare provider participants and patient participants were recruited in the study. Providers were interviewed to provide their feedback about the app based on screenshots of the app. Patients were interviewed after a 30 days of app usage.

RESULTS

The basic features of the app included symptom logging, vitals tracking, patient education, and push notifications. Overall, both parties provided positive feedback about the app. Areas to be improved mentioned by both parties included: the pain question asked in symptom tracking and the patient education section. Both parties agreed that it was essential to add the trend report of the logged symptoms.

CONCLUSIONS

The results indicated that providers were willing to use patient-reported data for disease management and perceived that the app had the potential to facilitate doctor-patient communication. Results also indicated that user engagement is the key to the success of app efficacy. To promote app engagement, app features should be tailored to individual patient's needs and goals. In the future, after it is upgraded, we plan to test the app usability and feasibility among a more diverse sample.

Impact of a Digital Tool on Pharmacy Students' Ability to Perform Medication Reviews: A Randomized Controlled Trial

Digital Medication Review Tools (DMRTs) are increasingly important in pharmacy practice. To ensure that young pharmacists are sufficiently competent to perform medication reviews after graduation, the introduction of DMRTs teaching in academic education is necessary. The aim of our study was to demonstrate the effect of DMRTs use on pharmacy students' performance when conducting a medication review (MR) in a randomized controlled pre-post design. Forty-one pharmacy students were asked to complete a MR within 60 min, followed by a 10-min consultation with (intervention group) and without a DMRT (control group). The MR performance was subdivided into four categories: communication skills, subjective and objective patient data, assessment, and plan. Performance was assessed using objective structured clinical examinations (OSCEs) and analytical checklists. With the use of DMRTs, the overall performance was improved by 17.0% compared to the control group (p < 0.01). Improvement through DMRTs was seen in the subcategories "Assessment" and "Plan". Furthermore, pharmacy students liked using DMRTs and felt more confident overall. Our study results demonstrate that DMRTs improve the performance of MRs, hence DMRTs should become an integral part of pharmacy curriculum. Consequently, digitally enabled pharmacists using DMRTs will be better prepared for their professional careers in pharmacy practice.

Towards better reporting of the proportion of days covered method in cardiovascular medication adherence: A scoping review and new tool TEN-SPIDERS

Although medication adherence is commonly measured in electronic datasets using the proportion of days covered (PDC), no standardized approach is used to calculate and report this measure. We conducted a scoping review to understand the approaches taken to calculate and report the PDC for cardiovascular medicines to develop improved guidance for researchers using this measure. After prespecifying methods in a registered protocol, we searched Ovid Medline, Embase, Scopus, CINAHL Plus and grey literature (1 July 2012 to 14 December 2020) for articles containing the terms "proportion of days covered" and "cardiovascular medicine", or synonyms and subject headings. Of the 523 articles identified, 316 were reviewed in full and 76 were included (93% observational studies; 47% from the USA; 2 grey literature articles). In 45 articles (59%), the PDC was measured from the first dispensing/claim date. Good adherence was defined as 80% PDC in 61 articles, 56% of which contained a rationale for selecting this threshold. The following parameters, important for deriving the PDC, were often not reported/unclear: switching (53%), early refills (45%), in-hospital supplies (45%), presupply (28%) and survival (7%). Of the 46 articles where dosing information was unavailable, 59% reported how doses were imputed. To improve the transparent and systematic reporting of the PDC, we propose the TEN-SPIDERS tool, covering the following PDC parameters: Threshold, Eligibility criteria, Numerator and denominator, Survival, Presupply, In-hospital supplies, Dosing, Early Refills, and Switching. Use of this tool will standardize reporting of the PDC to facilitate reliable comparisons of medication adherence estimates between studies.

Prevalence of statin intolerance: a meta-analysis

AIMS

Statin intolerance (SI) represents a significant public health problem for which precise estimates of prevalence are needed. Statin intolerance remains an important clinical challenge, and it is associated with an increased risk of cardiovascular events. This meta-analysis estimates the overall prevalence of SI, the prevalence according to different diagnostic criteria and in different disease settings, and identifies possible risk factors/conditions that might increase the risk of SI.

METHODS AND RESULTS

We searched several databases up to 31 May 2021, for studies that reported the prevalence of SI. The primary endpoint was overall prevalence and prevalence according to a range of diagnostic criteria [National Lipid Association (NLA), International Lipid Expert Panel (ILEP), and European Atherosclerosis Society (EAS)] and in different disease settings. The secondary endpoint was to identify possible risk factors for SI. A random-effects model was applied to estimate the overall pooled prevalence. A total of 176 studies [112 randomized controlled trials (RCTs); 64 cohort studies] with 4 143 517 patients were ultimately included in the analysis. The overall prevalence of SI was 9.1% (95% confidence interval 8.0-10%). The prevalence was similar when defined using NLA, ILEP, and EAS criteria [7.0% (6.0-8.0%), 6.7% (5.0-8.0%), 5.9% (4.0-7.0%), respectively]. The prevalence of SI in RCTs was significantly lower compared with cohort studies [4.9% (4.0-6.0%) vs. 17% (14-19%)]. The prevalence of SI in studies including both primary and secondary prevention patients was much higher than when primary or secondary prevention patients were analysed separately [18% (14-21%), 8.2% (6.0-10%), 9.1% (6.0-11%), respectively]. Statin lipid solubility did not affect the prevalence of SI [4.0% (2.0-5.0%) vs. 5.0% (4.0-6.0%)]. Age [odds ratio (OR) 1.33, P = 0.04], female gender (OR 1.47, P = 0.007), Asian and Black race (P < 0.05 for both), obesity (OR 1.30, P = 0.02), diabetes mellitus (OR 1.26, P = 0.02), hypothyroidism (OR 1.37, P = 0.01), chronic liver, and renal failure (P < 0.05 for both) were significantly associated with SI in the meta-regression model. Antiarrhythmic agents, calcium channel blockers, alcohol use, and increased statin dose were also associated with a higher risk of SI.

CONCLUSION

Based on the present analysis of >4 million patients, the prevalence of SI is low when diagnosed according to international definitions. These results support the concept that the prevalence of complete SI might often be overestimated and highlight the need for the careful assessment of patients with potential symptoms related to SI.

Monitoring Simvastatin Adherence in Patients With Coronary Heart Disease: A Proof-of-Concept Study Based on Pharmacokinetic Measurements in Blood Plasma

BACKGROUND

Poor statin adherence remains a public health concern associated with adverse outcomes. We evaluated the use of pharmacokinetic measurements to monitor adherence to simvastatin in patients with coronary heart disease (CHD).

METHODS

Eighteen patients with CHD taking an evening dose of simvastatin 20 mg (n = 7), 40 mg (n = 5), or 80 mg (n = 6) were examined at steady-state pharmacokinetics. Ten patients were instructed to interrupt simvastatin dosing and return for blood sampling for the subsequent 3 days. Dose-normalized plasma concentrations of simvastatin lactone and simvastatin acid and the sum of the 2 were evaluated to discriminate between adherent dosing and dose omission. Bioanalytical quantification was performed using liquid chromatography-tandem mass spectrometry.

RESULTS

A simvastatin acid cutoff of 1.0 × 10 -2 nmol -1 ·L -1 ·mg -1 identified 100% of those omitting 2 doses and 60% of those omitting a single dose. Simvastatin acid showed superior ability to discriminate dose omission, as well as the best agreement between samples handled at ambient and cool temperatures (median deviation 3.5%; interquartile range -2.5% to 13%). The cutoff for a morning dose schedule, with a similar ability to discriminate, was estimated at 2.0 × 10 -3 nmol -1 ·L -1 ·mg -1 .

CONCLUSIONS

The present method discriminated between adherence and reduced adherence to simvastatin therapy in patients with CHD. Sample handling is feasible for routine practice, and the assessment of adherence can be performed by direct measurement of simvastatin acid in a blood sample, according to defined cutoff values. Further studies validating the cutoff value and utility for clinical application are encouraged.

Estimated Atherosclerotic Cardiovascular Disease Risk Score: An Automated Decision Aid for Statin Therapy

BACKGROUND

Estimation of atherosclerotic cardiovascular disease (ASCVD) risk is a key step in cardiovascular disease (CVD) prevention, but it requires entering additional risk factor information into a computer. We developed a simplified ASCVD risk score that can be automatically calculated by the clinical laboratory when a fasting standard lipid panel is reported.

METHODS

Equations for an estimated ASCVD (eASCVD) risk score were developed for 4 race/sex groups (non-Hispanic White/Black, men/women), using the following variables: total cholesterol, high-density lipoprotein cholesterol, triglycerides, and age. The eASCVD score was derived using regression analysis to yield similar risk estimates as the standard ASCVD risk equations for non-diabetic individuals not on lipid-lowering therapy in the National Health and Nutrition Examination Survey (NHANES) (n = 6027).

RESULTS

At a cutpoint of 7.5%/10-year, the eASCVD risk score had an overall sensitivity of 69.1% and a specificity of 97.5% for identifying statin-eligible patients with at least intermediate risk based on the standard risk score. By using the sum of other risk factors present (systolic blood pressure >130 mmHg, blood pressure medication use, and cigarette use), the overall sensitivity of the eASCVD score improved to 93.7%, with a specificity of 92.3%. Furthermore, it showed 90% concordance with the standard risk score in predicting cardiovascular events in the Atherosclerosis Risk in Communities (ARIC) study (n = 14 742).

CONCLUSIONS

Because the automated eASCVD risk score can be computed for all patients with a fasting standard lipid panel, it could be used as an adjunctive tool for the primary prevention of ASCVD and as a decision aid for statin therapy.

A comprehensive assessment of statin discontinuation among patients who concurrently initiate statins and CYP3A4-inhibitor drugs; a multistate transition model

AIMS

To describe the 1-year direct and indirect transition probabilities to premature discontinuation of statin therapy after concurrently initiating statins and CYP3A4-inhibitor drugs.

METHODS

A retrospective new-user cohort study design was used to identify (N=160828) patients who concurrently initiated CYP3A4-inhibitors (diltiazem, ketoconazole, clarithromycin, others) and CYP3A4-metabolized statins (statin DDI exposed, n = 104774) vs. other statins (unexposed to statin DDI, n = 56054) from the MarketScan Commercial claims database (2012 - 2017). The statin DDI exposed and unexposed groups were matched (2:1) through propensity score-matching techniques. We applied a multistate transition model to compare the 1-year transition probabilities involving four distinct states (start, adverse drug events [ADEs], discontinuation of CYP3A4-inhibitor drugs, and discontinuation of statin therapy) between those exposed to statin DDIs, vs. unexposed. Statistically significant differences were assessed by comparing the 95% confidence intervals (CIs) of probabilities.

RESULTS

After concurrently starting stains and CYP3A, patients exposed to statin DDIs, vs. unexposed, were significantly less likely to discontinue statin therapy (71.4% [95% CI:71.1, 71.6] vs. 73.3% [95% CI:72.9, 73.6]) but more likely to experience an ADE (3.4% [95% CI:3.3, 3.5] vs. 3.2% [95% CI:3.1, 3.3]) and discontinue with CYP3A4-inhibitor therapy (21.0% [95% CI: 20.8, 21.3] vs. 19.5% [95% CI:19.2, 19.8]). ADEs did not change these associations because those exposed to statin DDIs, vs. unexposed, were still less likely to discontinue statin therapy but more likely to discontinue CYP3A4-inhibitor therapy after experiencing an ADE.

CONCLUSION

We did not observe any meaningful clinical differences in the probability of premature statin discontinuation between statin users exposed to statin DDIs, vs unexposed.

Drug Treatment of Hypercholesterolemia in Older Adults: Focus on Newer Agents

There is increasing research interest in cholesterol-lowering therapy in older patients. The newer lipid-lowering agents (the proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors evolocumab and alirocumab; the PCSK9 synthesis inhibitor inclisiran, and the adenosine triphosphate–citrate lyase inhibitor bempedoic acid) might also provide more options for the future treatment of older patients. Data analyses of the phase III outcome trials of the PCSK9 inhibitors suggest that their clinical benefits are maintained at older ages and that there is no increased relative risk of adverse events in older patients; however, data from patients aged ≥ 75 years and particularly aged ≥ 85 years are limited, and the trials did not collect information on the frailty status of patients. Frailty is a predictor of adverse outcomes, including mortality, and might help guide therapy decisions. To date, no outcome data are available for cardiovascular endpoints for the low-density lipoprotein cholesterol-lowering drugs inclisiran and bempedoic acid. Except for the risk of gout and tendon rupture with bempedoic acid, which remains to be further characterized in larger populations, the safety profile of the novel lipid-lowering agents in older patients seems favorable. The newer lipid-lowering agents could be added to other lipid-lowering medication or used as an alternative treatment in older patients with documented statin intolerance (as is already recommended in guidelines for the PCSK9 inhibitors), such as myopathy. Especially in older patients needing high-intensity therapy despite polypharmacy or certain comedications, the absence of clinically relevant drug–drug interactions with the PCSK9 inhibitors and inclisiran might be an advantage.

Use of statins and associated factors in nonagenarians in the Community of Madrid, Spain

Background

The role of statins in the management of dyslipidemia in elderly patients with different cardiovascular risks remains unclear.

Objective

To study use of statins and associated factors in subjects aged 90 or over in the Community of Madrid, Spain.

Methods

Observational, cross-sectional study that included all people aged 90 or more residing in the Community of Madrid as of December 31, 2015. The clinical information was obtained from the database that contains the electronic medical records collected by family doctors in primary care. Comorbidity data are collected according to the International Classification of Primary Care, Second Edition (ICPC-2).

Results

The study population comprised 59,423 subjects, with a mean age of 93.3 (2.5) years (25.8% males). Slightly more than one quarter of the population (28.2%) was in treatment with statins, 21.9% were in primary prevention, and 48.1% in secondary prevention. The multivariate analysis revealed the factors independently associated with statin treatment to be younger age, not being institutionalized, a higher Barthel score, a lower Charlson score, a higher body mass index, and a history of diabetes, dyslipidemia, chronic kidney disease, and cardiovascular disease.

Conclusions

A significant percentage of nonagenarians—mainly less frail patients with more comorbidities—in the Community of Madrid receive statin treatment. No clear efficacy has been demonstrated in reducing cardiovascular events in an age group with such a short life expectancy.

Association between CVDs and initiation and adherence to statin treatment in patients with newly diagnosed hypercholesterolaemia: a retrospective cohort study

OBJECTIVES

To evaluate the association between incident cardiovascular disease (CVD) and initiation and adherence to statin treatment for primary prevention of CVD in patients with newly diagnosed hypercholesterolaemia.

DESIGN

A population-based retrospective cohort study.

SETTING

This study used National Health Insurance Service-Health Screening Cohort (NHIS-HEALS) from Republic of Korea.

PARTICIPANTS

This study included 11 320 participants without previous history of CVD aged between 40 and 79 years who had elevated total cholesterol level (more than 240 mg/dL) and had initiated statin treatment within 24 months of the national health screening from 2004 to 2012 identified in the NHIS-HEALS.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome, CVD, was defined as first-ever admission or death due to ischaemic heart disease, acute myocardial infarction, revascularisation or stroke, or December 31 2013. The HRs of CVD according to statin adherence were calculated according to stratification by Systematic COronary Risk Evaluation.

RESULTS

Early statin initiation significantly lowered risk of CVD outcomes compared with late initiation (HR of late statin user, 1.24; 95% CI 1.02 to 2.51). Among early initiators, statin discontinuers had a significantly higher risk for CVD compared with persistent users (HR, 1.71; 95% CI 1.10 to 2.67), while statin reinitiators had an attenuated risk increase (HR 1.34, 95% CI 0.79 to 2.30).

CONCLUSIONS

Among statin users with newly diagnosed hypercholesterolaemia, early statin initiation is associated with lower CVD risk compared with late initiation. Furthermore, statin discontinuation is associated with increased risk of CVD, but reinitiation attenuated the risk.

Statin use and discontinuation in Danes age 70 and older: a nationwide drug utilisation study

BACKGROUND AND OBJECTIVE

There is limited evidence on the clinical effects of statins in older persons. We aimed to explore statin use and discontinuation patterns in Danes age 70 and older.

DESIGN

Register-based drug utilisation study.

SETTING

Danish nationwide health registries.

SUBJECTS

All Danish persons aged ≥70 years between 2011 and 2016.

MEASUREMENTS

(1) Monthly prevalence and (2) quarterly incidence of statin use, (3) characteristics of new users, (4) total amount of statin redeemed, (5) statin discontinuation rate between 2014 and 2016 in long-term statin users and (6) factors associated with discontinuation.

RESULTS

We identified 395,279 unique older statin users between 2011 and 2016. The prevalence increased from 30% in 2011 to 33% in 2016 (23% for primary prevention and 56% for secondary prevention in 2016). The quarterly incidence fell from 11 per 1,000 persons in 2011 to 7 per 1,000 persons in 2016. The prevalence was generally stable in those 70 to 79 years. In those aged ≥80 years, the prevalence increased despite decreasing incidence. The proportion of persons initiating for primary prevention decreased from 58% in 2011 to 52% in 2016. Approximately 19% of long-term statin users discontinued therapy between 2014 and 2016. Increasing age was the strongest predictor of statin discontinuation.

CONCLUSIONS

Approximately one in three Danes age ≥ 70 years were taking statins in 2016. The characteristics of incident users shifted between 2011 and 2016, with less people age 80 and older starting on statins and fewer people starting for primary prevention.

Non-Adherence to Statin Treatment in Older Patients with Peripheral Arterial Disease Depending on Persistence Status

The effectiveness of statins in secondary prevention of peripheral arterial disease (PAD) largely depends on patients’ adherence to treatment. The aims of our study were: (a) to analyze non-adherence during the whole follow-up in persistent patients, and only during persistence for non-persistent patients; (b) to identify factors associated with non-adherence separately among persistent and non-persistent patients. A cohort of 8330 statin users aged ≥65 years, in whom PAD was newly diagnosed between January 2012–December 2012, included 5353 patients persistent with statin treatment, and 2977 subjects who became non-persistent during the 5-year follow-up. Non-adherence was defined using the proportion of days covered <80%. Patient- and statin-related characteristics associated with non-adherence were identified with binary logistic regression. A significantly higher proportion of non-adherent patients was found among non-persistent patients compared to persistent subjects (43.6% vs. 29.6%; p < 0.001). Associated with non-adherence in both persistent and non-persistent patients was high intensity statin treatment, while in non-persistent patients, it was employment and increasing number of medications. In patients with a poor adherence during their persistent period, an increased risk for discontinuation may be expected. However, there is also non-adherence among persistent patients. There are differences in factors associated with non-adherence depending on patients’ persistence.

Real-world evaluation of the impact of statin intensity on adherence and persistence to therapy: A Scottish population-based study

Aim

To assess associations between statin intensity and adherence, persistence and discontinuation of statin therapy in Scotland.

Method

Retrospective cohort study, using linked electronic health records covering a period from January 2009 to December 2016. The study cohort included adult patients (≥18 years) newly initiating statins within Greater Glasgow and Clyde, Scotland. Study outcomes comprised adherence, discontinuation and persistence to treatment, stratified by three exposure groups (high, moderate and low intensity). Discontinuation and persistence were calculated using the refill‐gap and anniversary methods, respectively. Proportion of days covered (PDC) was used as a proxy for adherence. Kaplan‐Meier survival curves and Cox proportional hazard models were used to evaluate discontinuation, and associations between adherence/persistence and statin intensity were assessed using logistic regression.

Results

A total of 73 716 patients with a mean age of 61.4 ± 12.6 years were included; the majority (88.3%) received moderate intensity statins. Discontinuation rates differed between intensity levels, with high‐intensity patients less likely to discontinue treatment compared to those on moderate intensity (prior cardiovascular disease [CVD]: HR 0.43 [95% CI 0.34‐0.55]; no prior CVD: 0.80 [0.74‐0.86]). Persistence declined over time, and high‐intensity patients had the highest persistence rates. Overall, 52.6% of patients were adherent to treatment (PDC ≥ 80%), but adherence was considerably higher among high‐intensity patients (63.7%).

Conclusion

High‐intensity statins were associated with better persistence and adherence to treatment, but overall long‐term persistence and adherence remain a challenge, particularly among patients without prior CVD. This needs addressing.

Time to benefit and the long-term persistence of new users of oral bisphosphonates

INTRODUCTION

This study aimed to examine long-term persistence in new users of oral bisphosphonates in a population-wide cohort in Manitoba, Canada.

MATERIALS AND METHODS

A longitudinal observational study was conducted using administrative health data characterizing long-term bisphosphonate persistence in those who started treatment between 1997 and 2018. Treatment discontinuation was evaluated using Kaplan-Meier methods. Cox regression was used to examine associations between discontinuation and osteoporosis diagnosis, previous fractures, and age. A sub-analysis of users with FRAX scores examined the relationship between 10-year fracture risk estimations and discontinuation.

RESULTS

Of 42,249 new bisphosphonate users, median age was 71 years, with 88.6% being female. Median duration of bisphosphonate use was 0.95 years (IQR 0.25, 3.9 years). Overall, 47.9% of incident users persisted up to 1 year, 25.0% persisted up to 3 years, and 14.1% up to 5 years. Presence of an indication for bisphosphonate use was associated with decreased discontinuation risk. Persistence generally increased with age. Having a BMD test performed was a predictor of lower discontinuation. The strongest predictor was having an osteoporosis diagnosis [HR for discontinuation = 0.68 (95% CI 0.66, 0.70)]. In users with FRAX scores (n = 14,114), moderate-risk [HR = 0.86 (95% CI 0.77, 0.96)] and high-risk users [HR = 0.77 (95% CI 0.69, 0.85)] were less likely to discontinue compared to lower-risk users.

CONCLUSIONS

A rapid decline in bisphosphonate persistence was shown. Almost half of users would not be expected to achieve clinically relevant benefits with a persistence of less than 1 year. Allowing informed choice in high-risk patients may be the best way to focus on those likely to benefit and persist with treatment.

Patient-Associated Characteristics Influencing the Risk for Non-Persistence with Statins in Older Patients with Peripheral Arterial Disease

BACKGROUND AND OBJECTIVES

Secondary prevention of peripheral arterial disease includes administration of statins regardless of the patient's serum cholesterol level. Our study aimed to identify patient-associated risk factors for statin non-persistence and comparison of the explanatory power of models based on clusters of patient-associated characteristics.

METHODS

Our study cohort (n = 8330) was assembled from the database of the largest health insurance provider in the Slovak Republic. Statin users aged ≥ 65 years in whom peripheral arterial disease was diagnosed during 2012 were included. Patients were followed for 5 years; those with a treatment gap period of at least 6 months without statin prescription were classified as "non-persistent". The risk factors for non-persistence were identified within six models (sociodemographic, cardiovascular events, comorbid conditions, statin-related characteristics, cardiovascular co-medication and full model) using Cox regression. The explanatory power of models was assessed using Harrell's C-index.

RESULTS

At the end of the follow-up, 35.7% of patients were found to be non-persistent. The full model had the highest explanatory power (C = 0.632). Female sex, atorvastatin and rosuvastatin as initially administered statins, being a new statin user and an increasing co-payment were associated with an increased risk for non-persistence. Increasing age, history of ischaemic stroke, diabetes mellitus, general practitioner as index prescriber, increasing overall number of medications and co-administration of certain cardiovascular co-medications were associated with a lower likelihood for non-persistence.

CONCLUSIONS

Patients identified as high risk for non-persistence require special attention aimed at the improvement of their persistence with statin treatment.

Incidence of statin use in older adults with and without cardiovascular disease and diabetes mellitus, January 2008- March 2018

BACKGROUND

Data from randomized controlled trials and observational studies on older adults who take statins for primary prevention of atherosclerotic cardiovascular disease are limited. To determine the incidence of statin use in older adults with and without cardiovascular disease (CVD) and/or diabetes (DM), we conducted a descriptive observational study.

METHODS

The cohort consisted of health plan members in the NIH Collaboratory Distributed Research Network aged >75 years who had continuous drug and medical benefits for ≥183 days during the study period, January 1, 2008- March 31, 2018. We defined DM and CVD using diagnosis codes, and identified statins using dispensing data. Statin use was considered incident if a member had no evidence of statin exposure in the claims during the previous 183 days, and the use was considered long-term if statins were supplied for ≥180 days. Incidence rates were reported among members with and without CVD and/or diabetes, and stratified by year, sex, and age group.

RESULTS

Among 757,569 eligible members, 109,306 older adults initiated statins and 54,624 became long-term users. Health plan members with CVD had the highest incidence of statin use (143.9 initiators per 1,000 member-years for CVD & DM; 114.5 initiators per 1,000 member-years for CVD & No DM). Among health plan members without CVD, those with DM had rates of statin use that were over two times higher than members without DM (76.1 versus 34.5 initiators per 1,000 member-years, respectively). Statin initiation remained steady throughout 2008-2016, was slightly higher in males, and declined with increasing age.

CONCLUSION

Incidence of statin use varied by CVD and DM comorbidity, and was lowest among those without CVD. These results highlight the potential clinical equipoise to conduct large pragmatic clinical trials to generate evidence that could be used to inform future blood cholesterol guidelines.

A novel direct method to determine adherence to atorvastatin therapy in patients with coronary heart disease

AIMS

Objective methods to monitor statin adherence are needed. We have established a liquid chromatography-tandem mass spectrometry assay for quantification of atorvastatin and its metabolites in blood. This study aimed to develop an objective drug exposure variable with cut-off values to discriminate among adherence, partial adherence and nonadherence to atorvastatin therapy in patients with coronary heart disease.

METHODS

Twenty-five patients treated with atorvastatin 10 mg (n = 5), 20 mg (n = 6), 40 mg (n = 7) and 80 mg (n = 7) participated in a directly observed atorvastatin therapy study to confirm baseline adherence. After the directly observed therapy, half of the patients (test group) were instructed to stop taking atorvastatin and return for blood sample collection the subsequent 3 days. Levels of atorvastatin and metabolites were compared between the test group and the adherent control group.

RESULTS

The sum of parent drug and all measured primary metabolites correlated well with the atorvastatin dose administered (Spearman's rho = 0.71, 95% CI 0.44-0.87). The dose-normalized atorvastatin plus metabolites concentrations completely separated the partially adherent test group from the controls at 0.18 nM/mg after 3 days without atorvastatin. To reduce the risk of misinterpreting adherent patients as partially adherent, a corresponding cut-off at 0.10 nM/mg is proposed. A metabolite level of 2-OH atorvastatin acid <0.014 nmol/L provided the optimal cut-off for nonadherence.

CONCLUSION

A direct method to discriminate among adherence, partial adherence and nonadherence to atorvastatin therapy in patients with coronary heart disease has been developed. This tool may be important for novel studies on adherence and potentially useful in clinical practice.

Dynamics of switching, adherence, and persistence of dipeptidyl peptidase-4 inhibitors use: A nationwide cohort study

AIMS

To characterise the patterns of switching, adherence, and persistence among adults aged ≥18 years with diabetes prescribed dipeptidyl peptidase-4 inhibitors (DPP-4is) in Australia.

METHODS

The analysis included 15,915 adults newly prescribed DPP-4is (sitagliptin = 9576; vildagliptin = 1130; saxagliptin = 1126; linagliptin = 3560; and alogliptin = 523). Multivariable logistic regression model was used to compare the non-adherence (proportion of days covered [PDC] <0.80) rates whereas Cox proportional hazards regression models were used to compare switching and non-persistence (≥90-day gap) among different DPP4-is over 12-months.

RESULTS

Overall, 36.0% (5722/15,915) of DPP-4i users were non-adherent and 30.0% (4775/15,915) were non-persistent at 12-months. Compared to sitagliptin, vildagliptin, linagliptin, and alogliptin were not associated with higher non-adherence and non-persistence. However, saxagliptin was associated with a higher likelihood of being non-adherent (odds ratio 1.41, 95% confidence interval [CI] 1.23-1.60) or non-persistent (hazard ratio 1.27, 95% CI 1.15-1.42) compared to sitagliptin. Just 3.2% of people switched between different DPP-4is. Compared to sitagliptin, people initiated on vildagliptin, saxagliptin, alogliptin, and linagliptin were more likely to switch.

CONCLUSIONS

We found no significant differences in the adherence and persistence rates between alogliptin, vildagliptin or linagliptin and sitagliptin. However, saxagliptin was associated with higher non-adherence and non-persistence compared to sitagliptin. Switching was lowest amongst users of sitagliptin.

Adherence, Persistence, and Switching Among People Prescribed Sodium Glucose Co-transporter 2 Inhibitors: A Nationwide Retrospective Cohort Study

INTRODUCTION

Non-adherence and non-persistence to diabetes medications are associated with worse clinical outcomes. In this study, we aimed to characterise the 1-year switching, adherence, and persistence patterns among people with diabetes aged 18 years and older prescribed sodium-glucose co-transporter 2 inhibitors (SGLT2is) in Australia.

METHODS

Using data from Australia's national Pharmaceutical Benefits Scheme (PBS), we identified 11,981 adults (mean age 60.9 years; 40.5% female) newly initiated on SGLT2is (5993 dapagliflozin; 5988 empagliflozin) from September 2015 to August 2017. Adherence was assessed via the proportion of days covered (PDC), persistence was defined as the continuous use of SGLT2i without a gap of ≥ 90 days, and switching was defined as the first change from dapagliflozin to empagliflozin or vice versa. Generalised linear models (GLMs) were used to compare the adherence (PDC = continuous), logistic regression models were used to compare the likelihoods of being adherent (PDC ≥ 0.80), and Cox proportional hazard models were used to compare the likelihoods of persistence and switching between people prescribed empagliflozin and dapagliflozin.

RESULTS

Overall, 65.8% (7879/11,981) of people dispensed SGLT2is were adherent (PDC ≥ 0.80) and 72.1% (8644/11,981) were persistent at 12 months. The mean PDC was 0.79 ± 0.27. The use of empagliflozin was associated with higher adherence (PDC = continuous) [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.03-1.05], being adherent (OR 1.39, 95% CI 1.29-1.51), and persisting for 12 months [hazard ratio (HR) 1.14, 95% CI 1.06-1.22] compared with dapagliflozin. Only 4.3% (509/11,981) of people switched between the SGLT2i. Compared with dapagliflozin, people initiated on empagliflozin were less likely to switch [HR 0.46, 95% CI 0.38-0.55].

CONCLUSIONS

A considerable proportion of Australians prescribed SGLT2is were non-adherent or non-persistent. However, empagliflozin was associated with better adherence and persistence rates and a lower likelihood of switching compared with dapagliflozin.

Adherence and persistence to direct oral anticoagulants in atrial fibrillation: a population-based study

BACKGROUND

Despite simpler regimens than vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF), adherence (taking drugs as prescribed) and persistence (continuation of drugs) to direct oral anticoagulants are suboptimal, yet understudied in electronic health records (EHRs).

OBJECTIVE

We investigated (1) time trends at individual and system levels, and (2) the risk factors for and associations between adherence and persistence.

METHODS

In UK primary care EHR (The Health Information Network 2011-2016), we investigated adherence and persistence at 1 year for oral anticoagulants (OACs) in adults with incident AF. Baseline characteristics were analysed by OAC and adherence/persistence status. Risk factors for non-adherence and non-persistence were assessed using Cox and logistic regression. Patterns of adherence and persistence were analysed.

RESULTS

Among 36 652 individuals with incident AF, cardiovascular comorbidities (median CHA₂DS₂VASc[Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category] 3) and polypharmacy (median number of drugs 6) were common. Adherence was 55.2% (95% CI 54.6 to 55.7), 51.2% (95% CI 50.6 to 51.8), 66.5% (95% CI 63.7 to 69.2), 63.1% (95% CI 61.8 to 64.4) and 64.7% (95% CI 63.2 to 66.1) for all OACs, VKA, dabigatran, rivaroxaban and apixaban. One-year persistence was 65.9% (95% CI 65.4 to 66.5), 63.4% (95% CI 62.8 to 64.0), 61.4% (95% CI 58.3 to 64.2), 72.3% (95% CI 70.9 to 73.7) and 78.7% (95% CI 77.1 to 80.1) for all OACs, VKA, dabigatran, rivaroxaban and apixaban. Risk of non-adherence and non-persistence increased over time at individual and system levels. Increasing comorbidity was associated with reduced risk of non-adherence and non-persistence across all OACs. Overall rates of 'primary non-adherence' (stopping after first prescription), 'non-adherent non-persistence' and 'persistent adherence' were 3.5%, 26.5% and 40.2%, differing across OACs.

CONCLUSIONS

Adherence and persistence to OACs are low at 1 year with heterogeneity across drugs and over time at individual and system levels. Better understanding of contributory factors will inform interventions to improve adherence and persistence across OACs in individuals and populations.

Role of Statin Therapy in Primary Prevention of Cardiovascular Disease in Elderly Patients

Purpose of Review

Hypercholesterolemia and statin treatment are nowadays common among people older than 75 years, but clinical heterogeneity in this increasing age group is wide, and treatment decisions may differ from those in younger patients. Aim is to discuss the presentation, modifying factors, and treatment decisions of hypercholesterolemia (usually with statins) in older persons and focusing on primary prevention.

Recent Findings

There are no randomized controlled trials in persons older than 80 years at baseline. Randomized controlled trial findings in younger patients and 75+ subgroups and in observational studies support treatment in secondary prevention of atherosclerotic cardiovascular disease (ASCVD), but trial evidence in primary prevention is less clear. Available data do not imply specific harms in older patients, and, therefore, also, judicious primary prevention is possible. However, persons older than 75 years are biologically a very heterogeneous group with frequent frailty, comorbid conditions, and multiple concomitant drugs. All these, as well as personal preferences, must be taken into account in treatment decisions.

Summary

Statin treatment is only one way to prevent ASCVD in older people. Treatment of hypercholesterolemia should be started far before 75–80 years, and there is no need to discontinue statin treatment due to chronological age alone. After 75 years, treatment should be started in patients with ASCVD and judiciously in primary prevention. Like all prevention, statin treatment should be discontinued when palliative treatment is started. Ongoing and planned trials in 70+ individuals will give more information about primary prevention in older persons.

Predictors of first-year nonadherence and discontinuation of statins among older adults: a retrospective cohort study

AIMS

The aim of this study was to examine the level of and predictors of statin nonadherence and discontinuation among older adults.

METHODS

Among 22 340 Australians aged ≥65 years who initiated statin therapy from January 2014 to December 2015, we estimated the first-year nonadherence (proportion of days covered [PDC] <0.80) and discontinuation (≥90 days without statin coverage) rates. Predictors of nonadherence and discontinuation were examined via multivariable logistic regression. Analyses were performed separately for general beneficiaries (with a higher co-payment; n = 4841) and concessional beneficiaries (with a lower co-payment; n = 17 499).

RESULTS

During the one-year follow-up, 55.1% were nonadherent (concessional 52.6%; general beneficiaries 64.2%) and 44.7% discontinued statins (concessional 43.1%; general beneficiaries 50.4%). Among concessional beneficiaries, those aged 75-84 years and ≥85 years were more likely to discontinue than people aged 65-74 years (odds ratio 1.11, 95% confidence interval 1.04-1.19 and 1.38, 1.23-1.54, respectively). Diabetes was associated with an increased likelihood of nonadherence and discontinuation, while hypertension, angina and congestive heart failure were associated with a lower likelihood of nonadherence and discontinuation. Anxiety was associated with an increased likelihood of discontinuation, but polypharmacy (concurrent use of five or more drugs) was associated with a lower likelihood of nonadherence and discontinuation. Statin initiation by a general medical practitioner was associated with both increased likelihood of nonadherence and discontinuation. Similar predictors of nonadherence and discontinuation were identified for the general beneficiaries.

CONCLUSIONS

Among older adults prescribed statins, first-year nonadherence and discontinuation are high. Specific population subgroups such as people aged ≥85 years, those with diabetes or anxiety may require additional attention to improve statin adherence.