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McKechnie T, Brown Z, Lovrics O, Yang S, Kazi T, Eskicioglu C, Parvez E. Concurrent Use of Statins in Patients Undergoing Curative Intent Treatment for Triple Negative Breast Cancer: A Systematic Review and Meta-Analysis. Clin Breast Cancer 2024; 24:e103-e115. [PMID: 38296737 DOI: 10.1016/j.clbc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 02/02/2024]
Abstract
Pre-clinical studies in triple negative breast cancer (TNBC) suggest that statins may inhibit cell proliferation, promote cell-cycle arrest, induce apoptosis, change the tumor microenvironment, and improve effectiveness of other therapies. Observational studies have demonstrated variable effects from statin therapy on oncologic outcomes in these patients. As such, we aimed to pool previous data via a systematic review and meta-analysis to elucidate the impact of concurrent statin use on oncologic outcomes for patients with TNBC. Medline, EMBASE, CENTRAL, and PubMed were systematically searched from inception through to June 2022. Studies were included if they compared patients with TNBC receiving and not receiving statin therapy concurrently with oncologic treatment for curative intent in terms of recurrence and survival in a non-metastatic setting. The primary outcomes were 5-year disease-free survival (DFS) and 5-year overall survival (OS). A pairwise meta-analyses was performed using inverse variance random effects. Risk of bias was assessed with the ROBINS-I and the GRADE approach was conducted to assess quality of evidence. From 4014 citations, 5 studies with 625 patients on statin therapy and 2707 patients not on statin therapy were included. There was a significant increase in 5-year DFS for patients on statin therapy compared to patients not on statin therapy (OR 1.44, 95% CI 1.04-1.98, P = .03). No significant difference was noted in 5-year OS between the 2 groups (OR 1.12, 95% CI 0.86-1.47, P = .40). Included studies were at moderate-to-high risk of bias. The GRADE quality of evidence was very low. This review presents very low-quality evidence that concurrent use of statins with oncologic treatment may potentially improve long-term DFS for patients with TNBC undergoing curative intent therapy. Future research by way of large, prospective study is required to further clarify the clinical utility of statins on patients undergoing treatment for TNBC.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Zachary Brown
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Olivia Lovrics
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Shuling Yang
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tania Kazi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Elena Parvez
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Patient adherence to fully reimbursed proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) treatment. Wien Klin Wochenschr 2023:10.1007/s00508-023-02154-y. [PMID: 36808306 DOI: 10.1007/s00508-023-02154-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/12/2023] [Indexed: 02/23/2023]
Abstract
AIMS Proprotein convertase subtilisin/kexin-type 9 inhibitor (PCSK9i) treatment reduces cardiovascular events when taken over a long time for secondary prevention. Data on treatment adherence are scarce and maybe affected by co-payment of patients. The aim of this study was to elucidate PCSK9i treatment adherence in a setting of full cost coverage as it is the case in a number of European countries. METHODS AND RESULTS Baseline data and prescription patterns of all 7302 patients with PCSK9i prescriptions dispensed on the account of Austrian Social Insurances between September 2015 and December 2020 were retrieved and analyzed. A gap of ≥ 60 days between prescriptions was defined as treatment discontinuation. Patient adherence was evaluated as the proportion of days covered (PDC) over the observation period and treatment discontinuation rates were investigated by the Kaplan-Meier method. The mean PDC was 81.8% and was significantly lower in female patients. A PDC of ≥ 80% indicating adequate adherence was found in 73.8%. Of the study population 27.4% discontinued PCSK9i treatment and 49.2% thereof re-initiated treatment during the observation period. Most of the patients who discontinued treatment did so within the first year. Male patients and patients under 64 years showed significantly lower discontinuation and higher re-initiation rates. CONCLUSION Considering the high PDC and low discontinuation rates, the majority of patients adhere to PCSK9i treatment. Hence, in a system where PCSK9i treatment is made available at virtually no costs for patients this highly effective treatment is well-accepted as a long-term treatment.
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Muacevic A, Adler JR, Nadig V, Kunkes J. Statin-Induced Myositis with Concomitant Myocarditis. Cureus 2022; 14:e31871. [PMID: 36579236 PMCID: PMC9792361 DOI: 10.7759/cureus.31871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 11/27/2022] Open
Abstract
Statins are commonly prescribed medications that provide many significant cardiovascular benefits for both primary and secondary prevention in patients with and without coronary artery disease. Known adverse effects of these medications include varying degrees of muscle toxicity, including myalgia, myopathy, and rare cases of necrotizing myositis, hepatic dysfunction, and central nervous system changes. Despite known adverse effects, statins are rarely associated with myocarditis. Statins can cause skeletal muscle myopathy and myositis by upregulating HMG-CoA reductase (HMGCR) in muscle tissue, resulting in antibody-mediated inflammation. A similar proposed mechanism is likely possible within cardiac myocytes. We present a rare case of statin-induced necrotizing myositis with concomitant cardiac involvement. Severe skeletal muscle myositis was confirmed by lower extremity MRI and biopsy findings. In association, elevated and plateaued high-sensitivity troponin without evidence of cardiac ischemia warranted cardiac MRI, which further confirmed myocarditis due to inflammation within a non-vascular distribution. Given its rare presentation, the treatment for statin-induced cardiac toxicity is unclear; however, the patient in this case report was treated with pulse-dose intravenous steroids and indefinite discontinuation of statin medications.
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Dembowski E, Freedman I, Grundy SM, Stone NJ. Guidelines for the management of hyperlipidemia: How can clinicians effectively implement them? Prog Cardiovasc Dis 2022; 75:4-11. [PMID: 36395880 DOI: 10.1016/j.pcad.2022.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022]
Abstract
Guidelines support lowering cholesterol to decrease atherosclerotic cardiovascular disease (ASCVD) risk across the entire lifespan with intensive lifestyle intervention, as well as statin and non-statin pharmacotherapy for those at highest risk. Modest improvements in the initiation, use, and adherence to statin therapy in patients with ASCVD have occurred over the past decades. However, studies continue to document a less than desired implementation of guidelines highlighting a substantial and persistent treatment gap. The success of implementation depends on the consideration of a variety of barriers that exist throughout the healthcare delivery system. Further research is needed to comprehensively evaluate these barriers in order to develop appropriate and sustainable interventions to improve guideline implementation.
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Affiliation(s)
- Ewa Dembowski
- Northwestern University Feinberg School of Medicine, Division of Cardiology.
| | - Isaac Freedman
- Northwestern University Feinberg School of Medicine, Division of Cardiology
| | - Scott M Grundy
- Center for Human Nutrition of the University of Texas, Texas Southwestern Medical Center at Dallas
| | - Neil J Stone
- Northwestern University Feinberg School of Medicine, Department of Preventive Medicine
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Bytyçi I, Penson PE, Mikhailidis DP, Wong ND, Hernandez AV, Sahebkar A, Thompson PD, Mazidi M, Rysz J, Pella D, Reiner Ž, Toth PP, Banach M. Prevalence of statin intolerance: a meta-analysis. Eur Heart J 2022; 43:3213-3223. [PMID: 35169843 PMCID: PMC9757867 DOI: 10.1093/eurheartj/ehac015] [Citation(s) in RCA: 124] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/10/2022] [Indexed: 07/25/2023] Open
Abstract
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.
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Affiliation(s)
- Ibadete Bytyçi
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Kosovo
| | - Peter E Penson
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Nathan D Wong
- Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine School of Medicine Predictive Health Diagnostics, Irvine, CA, USA
| | - Adrian V Hernandez
- Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, University of Connecticut School of Pharmacy, Storrs, CT, USA
- Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Paul D Thompson
- Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, USA
- Department of Internal Medicine, University of Connecticut, Farmington, CT, USA
| | - Mohsen Mazidi
- Department of Twin Research and Genetic Epidemiology, King’s College London, London, UK
- Department of Nutritional Sciences, King’s College London, London, UK
| | - Jacek Rysz
- Department of Hypertension, Nephrology and Family Medicine, Medical University of Lodz (MUL), Lodz, Poland
| | - Daniel Pella
- 2nd Department of Cardiology, Faculty of Medicine, Pavol Jozef Safarik University and East Slovak Institute of Cardiovascular Diseases, Kosice, Slovakia
| | - Željko Reiner
- Department of Internal Diseases, University Hospital Center Zagreb, School of Medicine, Zagreb University, Zagreb, Croatia
| | - Peter P Toth
- CGH Medical Center, Sterling, IL, USA
- Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Cai C, Love BL, Yunusa I, Reeder CE. Applying Mixture Cure Survival Modeling to Medication Persistence Analysis. Pharmacoepidemiol Drug Saf 2022; 31:788-795. [DOI: 10.1002/pds.5441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/15/2022] [Accepted: 04/12/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Chao Cai
- Department of Clinical Pharmacy and Outcomes Sciences College of Pharmacy University of South Carolina
| | - Bryan L. Love
- Department of Clinical Pharmacy and Outcomes Sciences College of Pharmacy University of South Carolina
| | - Ismaeel Yunusa
- Department of Clinical Pharmacy and Outcomes Sciences College of Pharmacy University of South Carolina
| | - C. E. Reeder
- Department of Clinical Pharmacy and Outcomes Sciences College of Pharmacy University of South Carolina
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Concurrent use of statins and neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:2715-2727. [PMID: 34498133 DOI: 10.1007/s00384-021-04016-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Statins are used primarily in patients with cardiovascular disease. More recently, they have demonstrated benefit in oncology patients. In vitro models have shown decreased rectal tumor cell viability in cells receiving chemoradiation and statin therapy. In vivo models have been less clear. This study aims to elucidate the impact of concurrent use of statins on the efficacy of neoadjuvant therapy for rectal cancer. METHODS Search of Medline, EMBASE, and CENTRAL was performed. Articles were included if they reported complete pathological response (pCR), long-term oncologic outcomes, or chemoradiotherapy-induced toxicity in patients with rectal cancer receiving concurrent statin and neoadjuvant therapy. A pairwise meta-analyses was performed using inverse variance random effects. RESULTS From 1564 citations, six studies with 726 patients on statin therapy (24.5% female, age: 63.6 years) and 1863 patients not on statin therapy (35.6% female, age: 60.9 years) were included. There was no significant difference in pCR rate between patients on statin therapy and patients not on statin therapy (RR 1.23, 95%CI 0.98-1.54, p = 0.08). Similarly, no difference existed between groups in long-term oncologic outcomes (5-year overall survival: RR 1.03, 95%CI 0.86-1.24, p = 0.75; 5-year disease-free survival: RR 1.04, 95%CI 0.85-1.26, p = 0.73). Chemoradiotherapy-induced toxicities were similar between groups. CONCLUSION The concurrent use of statin and neoadjuvant therapy did not significantly impact short- or long-term oncologic outcomes in patients with rectal cancer. Yet, despite pooling of data, this study remained inadequately powered. Larger, prospective studies are required to further elucidate the impact of statins on patients undergoing neoadjuvant therapy for rectal cancer.
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Santoleri F, Romagnoli A, Costantini A. Adherence and persistence in the use of statins and ezetimibe over 8 years in a real-life study. Curr Med Res Opin 2021; 37:2061-2066. [PMID: 34515600 DOI: 10.1080/03007995.2021.1980777] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Adherence and persistence to treatment are crucial in statin therapy as they are synonymous with efficacy and quality of care. The aim of this study was the real-life assessment of adherence and persistence over eight years in treatment-naive patients receiving atorvastatin, lovastatin, simvastatin, pravastatin, ezetimibe. METHODS Adherence to treatment was calculated using the 'proportion of days covered' method and persistence as the difference between the start and end of the therapy under study. RESULTS Treatment adherence was consistently above 85% for all drugs under study in each year. Treatment persistence was shown to half halved already from the first year. CONCLUSION Adherent patients had a higher persistence than non-adherent patients.
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Zhu Y, Chiang C, Wang L, Brock G, Milks MW, Cao W, Zhang P, Zeng D, Donneyong M, Li L. A multistate transition model for statin-induced myopathy and statin discontinuation. CPT Pharmacometrics Syst Pharmacol 2021; 10:1236-1244. [PMID: 34562311 PMCID: PMC8520747 DOI: 10.1002/psp4.12691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/10/2021] [Accepted: 07/07/2021] [Indexed: 12/12/2022] Open
Abstract
The overarching goal of this study was to simultaneously model the dynamic relationships among statin exposure, statin discontinuation, and potentially statin-related myopathic outcomes. We extracted data from the Indiana Network of Patient Care for 134,815 patients who received statin therapy between January 4, 2004, and December 31, 2008. All individuals began statin treatment, some discontinued statin use, and some experienced myopathy and/or rhabdomyolysis while taking the drug or after discontinuation. We developed a militate model to characterize 12 transition probabilities among six different states defined by use or discontinuation of statin and its associated myopathy or rhabdomyolysis. We found that discontinuation of statin therapy was common and frequently early, with 44.4% of patients discontinuing therapy after 1 month, and discontinuation is a strong indicator for statin-induced myopathy (risk ratio, 10.8; p < 0.05). Women more likely than men (p < 0.05) and patients aged 65 years and older had a higher risk than those aged younger than 65 years to discontinue statin use or experience myopathy. In conclusion, we introduce an innovative multistate model that allows clear depiction of the relationship between statin discontinuation and statin-induced myopathy. For the first time, we have successfully demonstrated and quantified the relative risk of myopathy between patients who continued and discontinued statin therapy. Age and sex were two strong risk factors for both statin discontinuation and incident myopathy.
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Affiliation(s)
- Yuxi Zhu
- Division of BiostatisticsCollege of Public HealthThe Ohio State UniversityColumbusOhioUSA
- Department of Biomedical InformaticsCollege of MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Chien‐Wei Chiang
- Department of Biomedical InformaticsCollege of MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Lei Wang
- Department of Biomedical InformaticsCollege of MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Guy Brock
- Department of Biomedical InformaticsCollege of MedicineThe Ohio State UniversityColumbusOhioUSA
| | - M. Wesley Milks
- Department of Internal MedicineCollege of MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Weidan Cao
- Department of Biomedical InformaticsCollege of MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Pengyue Zhang
- BiostatisticsSchool of MedicineIndiana UniversityIndianapolisIndianaUSA
| | - Donglin Zeng
- Department of BiostatisticsUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Macarius Donneyong
- Division of Pharmacy Practice and ScienceCollege of PharmacyThe Ohio State UniversityColumbusOhioUSA
| | - Lang Li
- Department of Biomedical InformaticsCollege of MedicineThe Ohio State UniversityColumbusOhioUSA
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Boettiger DC, Kerr S, Chattranukulchai P, Siwamogsatham S, Avihingsanon A. Maintenance of statin therapy among people living with HIV. AIDS 2021; 35:567-574. [PMID: 33252492 DOI: 10.1097/qad.0000000000002769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Statins play a critical role in reducing the elevated risk of atherosclerotic cardiovascular disease (ASCVD) among people living with HIV (PLHIV). However, maintaining statin therapy is difficult and may be impeded further in PLHIV due to the risk of antiretroviral therapy (ART)/statin interactions. We estimated rates of statin discontinuation and reinitiation, and the percentage of days covered by statin use among PLHIV on ART, and investigated factors associated with these outcomes. DESIGN Observational cohort study. METHODS Clinical data from individuals attending the HIV-NAT Centre in Bangkok, Thailand between 2001 and 2020 were analyzed using Kaplan-Meier curves, competing-risk regression, and generalized estimating equations. Discontinuation was defined as statin cessation lasting 90 days. RESULTS Data on 318 PLHIV were included. After 1, 3, and 5 years, 22.3, 50.8, and 61.1% had discontinued statin use, respectively. Among those who discontinued (n = 178), 52.0% reinitiated statin use within 5 years. Factors associated with statin discontinuation were low education level, fewer concomitant medications, and lack of ASCVD. Factors associated with statin reinitiation were older age, diabetes, and high levels of LDL cholesterol. The adjusted mean percentage of days covered by a statin was 86.7, 61.1, and 58.1% in the 6 months prior to 1, 3, and 5 years of follow-up, respectively. CONCLUSION Maintenance of statin therapy is poor among PLHIV on ART but is not associated with using contraindicated antiretroviral/statin combinations. A better understanding of statin use in PLHIV will aid clinicians treating individuals and policy makers designing interventions for population-level ASCVD risk reduction.
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Affiliation(s)
- David C Boettiger
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Institute for Health and Aging, University of California, San Francisco, San Francisco, California, USA
- Faculty of Medicine, Biostatistics Excellence Centre, Chulalongkorn University, King Chulalongkorn Memorial Hospital
| | - Stephen Kerr
- Faculty of Medicine, Biostatistics Excellence Centre, Chulalongkorn University, King Chulalongkorn Memorial Hospital
- HIV-NAT Research Collaboration/Thai Red Cross AIDS Research Centre
| | | | | | - Anchalee Avihingsanon
- HIV-NAT Research Collaboration/Thai Red Cross AIDS Research Centre
- Tuberculosis Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Kytö V, Sipilä J, Tornio A, Rautava P, Gunn J. Sex-Based Outcomes After Coronary Artery Bypass Grafting. Ann Thorac Surg 2021; 112:1974-1981. [PMID: 33484674 DOI: 10.1016/j.athoracsur.2021.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/09/2020] [Accepted: 01/04/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Sex is suggested to influence outcomes after coronary artery bypass grafting (CABG), although evidence on long-term mortality is controversial and cardiovascular outcome data are lacking. We studied sex differences in outcomes after isolated CABG. METHODS Consecutive patients with first-time isolated CABG for stable coronary artery disease between 2004 and 2014 in Finland were retrospectively recognized from national registry (n = 14,681; 21% women). Propensity scoring and inverse probability weighting were used to adjust for baseline features. Median follow-up was 10.0 (maximum 14.6) years. RESULTS Cumulative major adverse cardiovascular event (myocardial infarction, stroke, or cardiovascular death) rate was 44.5% in men and 49.9% in women during follow-up (hazard ratio [HR], 0.98; P = .633). All-cause mortality was 48.5% in men vs 46.0% in women (HR, 1.20; 95% confidence interval, 1.11-1.30; P < .0001), and cardiovascular mortality was 29.5% vs 31.3% (P = .625). Stroke rate was comparable between men and women (19.4% vs 23.6%; P = .625). Myocardial infarction occurred more frequently in women (20.0% vs 23.6%; HR, 0.84; 95% confidence interval, 0.75-0.95; P = .005). Redo revascularization was performed to 12.8% of women and to 12.6% of men (P = .100). Anticoagulation was more frequently used by men and adenosine diphosphate inhibitors and diuretics were more frequently used by women after CABG. Usage of statins, angiotensin-converting-enzyme inhibitors or angiotensin-blockers, beta-blockers, calcium-channel blockers, or nitrates did not differ between sexes after CABG. CONCLUSIONS Sex was not an independent predictor of long-term major adverse cardiovascular events after CABG in this population-based cohort study. However, men had higher long-term all-cause mortality and women higher risk of myocardial infarction. Long-term outcomes should be accounted for when considering sex as a risk factor for CABG.
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Affiliation(s)
- Ville Kytö
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland; Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland; Center for Population Health Research, Turku University Hospital, University of Turku, Turku, Finland; Administrative Center, Hospital District of Southwest Finland, Turku, Finland.
| | - Jussi Sipilä
- Department of Neurology, North Karelia Central Hospital, Siun Sote, Joensuu, Finland; Department of Neurology, University of Turku, Turku, Finland
| | - Aleksi Tornio
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland; Unit of Clinical Pharmacology, Turku University Hospital, Turku, Finland
| | - Päivi Rautava
- Department of Public Health, University of Turku, Turku, Finland; Turku Clinical Research Centre, Turku University Hospital, Turku, Finland
| | - Jarmo Gunn
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland
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12
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Enright C, Peterson A, Eickhoff J, Dodge A. Statin adherence and LDL-C reduction in a pediatric population. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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13
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Sigglekow F, Horsburgh S, Parkin L. Statin adherence is lower in primary than secondary prevention: A national follow-up study of new users. PLoS One 2020; 15:e0242424. [PMID: 33211724 PMCID: PMC7676659 DOI: 10.1371/journal.pone.0242424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 11/02/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Maintaining adherence to statins reduces the risk of an initial cardiovascular disease (CVD) event in high-risk individuals (primary prevention) and additional CVD events following the first event (secondary prevention). The effectiveness of statin therapy is limited by the level of adherence maintained by the patient. We undertook a nationwide study to compare adherence and discontinuation in primary and secondary prevention patients. METHODS Dispensing data from New Zealand community pharmacies were used to identify patients who received their first statin dispensing between 2006 and 2011. The Medication Possession Ratio (MPR) and proportion who discontinued statin medication was calculated for the year following first statin dispensing for patients with a minimum of two dispensings. Adherence was defined as an MPR ≥ 0.8. Previous CVD was identified using hospital discharge records. Multivariable logistic regression was used to control for demographic and statin characteristics. RESULTS Between 2006 and 2011 289,666 new statin users were identified with 238,855 (82.5%) receiving the statin for primary prevention compared to 50,811 (17.5%) who received it for secondary prevention. The secondary prevention group was 1.55 (95% CI 1.51-1.59) times as likely to be adherent and 0.67 (95% CI 0.65-0.69) times as likely to discontinue statin treatment than the primary prevention group. An early gap in statin coverage increased the odds of discontinuing statin treatment. CONCLUSION Adherence to statin medication is higher in secondary prevention than primary prevention. Within each group, a range of demographic and treatment factors further influences adherence.
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Affiliation(s)
- Finn Sigglekow
- Department of Preventive and Social Medicine, Otago Medical School—Dunedin Campus, University of Otago, Dunedin, New Zealand
| | - Simon Horsburgh
- Department of Preventive and Social Medicine, Otago Medical School—Dunedin Campus, University of Otago, Dunedin, New Zealand
- Pharmacoepidemiology Research Network, University of Otago, Dunedin, New Zealand
- * E-mail:
| | - Lianne Parkin
- Department of Preventive and Social Medicine, Otago Medical School—Dunedin Campus, University of Otago, Dunedin, New Zealand
- Pharmacoepidemiology Research Network, University of Otago, Dunedin, New Zealand
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14
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Aguilar-Palacio I, Rabanaque MJ, Maldonado L, Chaure A, Abad-Díez JM, León-Latre M, Casasnovas JA, Malo S. New Male Users of Lipid-Lowering Drugs for Primary Prevention of Cardiovascular Disease: The Impact of Treatment Persistence on Morbimortality. A Longitudinal Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17207653. [PMID: 33092211 PMCID: PMC7593937 DOI: 10.3390/ijerph17207653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/06/2020] [Accepted: 10/17/2020] [Indexed: 12/13/2022]
Abstract
The objective of this study was to analyse persistence to lipid-lowering drug use for primary prevention of cardiovascular disease (CVD) in a new users cohort, to explore all-cause and cardiovascular related morbidity, comorbidity and mortality in this group and, finally, to study the relationship between persistence and morbimortality. We selected subjects who started lipid-lowering treatment for primary prevention of CVD between 1 January 2010 and 31 December 2017 (N = 1424), and classified them as treatment-persistent or -nonpersistent. Bivariate analyses were performed to compare sociodemographic and clinical variables, morbimortality and time to event between groups. The association between morbidities was explored using comorbidity network analysis. The effect of persistence was analysed using logistic regression and Cox survival analyses. Only 38.7% of users were persistent with treatment. Persistent and nonpersistent users had similar sociodemographic and clinical profiles, although differed in age, smoking status, and glycemia. Comorbidity networks revealed that the number of co-occurring diagnoses was higher in nonpersistent than persistent users. Adjusted analyses indicated a protective effect of treatment persistence, especially against major adverse cardiovascular events (MACE), but this effect was not statistically significant. Observational studies are crucial to characterize real-world effectiveness.
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Affiliation(s)
- Isabel Aguilar-Palacio
- Department of Preventive Medicine and Public Health, University of Zaragoza, 50009 Zaragoza, Spain; (M.J.R.); (S.M.)
- Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain; (M.L.-L.); (J.A.C.)
- GRISSA Research Group, 50009 Zaragoza, Spain; (A.C.); (J.M.A.-D.)
- Correspondence:
| | - María José Rabanaque
- Department of Preventive Medicine and Public Health, University of Zaragoza, 50009 Zaragoza, Spain; (M.J.R.); (S.M.)
- Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain; (M.L.-L.); (J.A.C.)
- GRISSA Research Group, 50009 Zaragoza, Spain; (A.C.); (J.M.A.-D.)
| | - Lina Maldonado
- Department of Economic Structure, Economic History and Public Economics, University of Zaragoza, 50005 Zaragoza, Spain;
| | - Armando Chaure
- GRISSA Research Group, 50009 Zaragoza, Spain; (A.C.); (J.M.A.-D.)
| | - José María Abad-Díez
- GRISSA Research Group, 50009 Zaragoza, Spain; (A.C.); (J.M.A.-D.)
- Department of Health, Aragon Health Service (SALUD), 50017 Zaragoza, Spain
| | - Montse León-Latre
- Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain; (M.L.-L.); (J.A.C.)
| | - José Antonio Casasnovas
- Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain; (M.L.-L.); (J.A.C.)
- Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV), 28029 Madrid, Spain
| | - Sara Malo
- Department of Preventive Medicine and Public Health, University of Zaragoza, 50009 Zaragoza, Spain; (M.J.R.); (S.M.)
- Fundación Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain; (M.L.-L.); (J.A.C.)
- GRISSA Research Group, 50009 Zaragoza, Spain; (A.C.); (J.M.A.-D.)
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15
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Koren MJ, Sabatine MS, Giugliano RP, Langslet G, Wiviott SD, Ruzza A, Ma Y, Hamer AW, Wasserman SM, Raal FJ. Long-Term Efficacy and Safety of Evolocumab in Patients With Hypercholesterolemia. J Am Coll Cardiol 2020; 74:2132-2146. [PMID: 31648705 DOI: 10.1016/j.jacc.2019.08.1024] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 07/16/2019] [Accepted: 08/04/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Evolocumab and other anti-PCSK9 antibodies reduced adverse cardiovascular outcomes in clinical trials of high-risk patients over <3 years median treatment duration. OBJECTIVES The OSLER-1 trial (Open Label Study of Long Term Evaluation Against LDL-C Trial) evaluated longer-term effects of evolocumab during open-label hypercholesterolemia treatment for up to 5 years. METHODS Patients randomized to standard of care (SOC) or evolocumab 420 mg monthly (evolocumab + SOC) for year 1. After year 1, patients could enter the all-evolocumab period and receive evolocumab + SOC for an additional 4 years. The authors analyzed the persistence of lipid effects and exposure-dependent safety focusing on yearly rates of adverse events (AEs) and anti-drug antibodies over 4.951 patient-years of observation. RESULTS A total of 1,255 patients (safety analysis population) randomized into the year 1 SOC-controlled period and received ≥1 evolocumab dose (mean ± SD age 57 ± 12 years; 53% female). A total of 1,151 patients (efficacy analysis population) progressed to the all-evolocumab period (year 2 and beyond). Evolocumab + SOC persistently lowered mean ± SE low-density lipoprotein cholesterol (LDL-C) by 56% ± 0.6% (n = 1,071), 57% ± 0.8% (n = 1,001), 56% ± 0.8% (n = 943), and 56% ± 0.8% (n = 803) after approximately 2, 3, 4, and 5 years, respectively, from randomization. Mean baseline LDL-C decreased from 140 to 61 mg/dl on treatment. Yearly serious AE rates during evolocumab + SOC ranged from 6.9% to 7.9%, comparable to the 6.8% rate in SOC patients during year 1. Evolocumab discontinuation due to AEs occurred in 5.7% of patients. Two SOC and 2 evolocumab + SOC patients developed new, transient, binding anti-drug antibodies; no neutralizing antibodies were observed. CONCLUSIONS The OSLER-1 trial demonstrated consistently excellent LDL-C-lowering efficacy, tolerance, and safety of evolocumab, with no neutralizing antibodies detected, throughout the longest-duration study of a PCSK9 inhibitor reported to date. (Open Label Study of Long Term Evaluation Against LDL-C Trial [OSLER-1]; NCT01439880).
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Affiliation(s)
- Michael J Koren
- Jacksonville Center for Clinical Research, Jacksonville, Florida.
| | - Marc S Sabatine
- Thrombolysis In Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert P Giugliano
- Thrombolysis In Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Stephen D Wiviott
- Thrombolysis In Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrea Ruzza
- Amgen, One Amgen Center Drive, Thousand Oaks, California
| | - Yuhui Ma
- Amgen, One Amgen Center Drive, Thousand Oaks, California
| | - Andrew W Hamer
- Amgen, One Amgen Center Drive, Thousand Oaks, California
| | | | - Frederick J Raal
- The Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Gallego-Colon E, Daum A, Yosefy C. Statins and PCSK9 inhibitors: A new lipid-lowering therapy. Eur J Pharmacol 2020; 878:173114. [PMID: 32302598 DOI: 10.1016/j.ejphar.2020.173114] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/17/2020] [Accepted: 04/09/2020] [Indexed: 11/28/2022]
Abstract
The clinical benefit of lipid-lowering therapies is to reduce circulating levels of atherogenic particles and to ameliorate the risk of atherosclerotic cardiovascular disease (ASCVD). The completion of two major clinical trials on PCSK9 inhibitors (PCSK9i), the FOURIER and the ODYSSEY outcome trials, has marked the beginning of a new era of lipid-lowering drugs. PCSK9i, evolocumab and alirocumab, are monoclonal antibodies that inactivate the liver proprotein convertase subtilisin kexin 9 (PCSK9). Inhibition of PCSK9 increases the number of low-density lipoprotein (LDL) receptors available leading to a profound reduction in circulating LDL particles. By preventing LDL receptor destruction, PCSK9i as adjunct to statin therapy can reduce LDL-C by 50-60% above that achieved by statin therapy alone. In addition, PCSK9i in combination with high-dose statins may reduce cardiovascular events and all-cause mortality in patients with clinical ASCVD. Based on evidence from clinical trials, the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines for the management of dyslipidemias now include the use of PCSK9i to very high-risk ASCVD patients who are not achieving treatment goals on a maximum tolerated dose of a statin and ezetimibe. However, the cost-effectiveness of PCSK9i therapy is limited to secondary prevention in high-risk patients. This review outlines the main clinical trials leading to a change in the guidelines, clinical practice as well as the future challenges of PCSK9i therapy.
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Affiliation(s)
- Enrique Gallego-Colon
- Cardiology Department, Barzilai University Medical Center, Ben-Gurion University, Ashkelon, Israel.
| | - Aner Daum
- Cardiology Department, Barzilai University Medical Center, Ben-Gurion University, Ashkelon, Israel
| | - Chaim Yosefy
- Cardiology Department, Barzilai University Medical Center, Ben-Gurion University, Ashkelon, Israel
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Bens A, Langballe R, Bernstein JL, Cronin-Fenton D, Friis S, Mellemkjaer L. Preventive drug therapy and contralateral breast cancer: summary of the evidence of clinical trials and observational studies. Acta Oncol 2019; 58:1581-1593. [PMID: 31393200 DOI: 10.1080/0284186x.2019.1643915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Breast cancer patients have a lifelong 2-4-fold increased risk of developing a second primary tumor in the contralateral breast compared with the risk for a first primary breast cancer in the general female population. Prevention of contralateral breast cancer (CBC) has received increased attention during recent decades. Here, we summarize and discuss the available literature on drug preventive therapy and CBC.Results: The endocrine-targetting drugs, tamoxifen and aromatase inhibitors are used as standard adjuvant treatment for estrogen receptor (ER)-positive breast cancer. Both are associated with relative risk reductions of CBC of up to 50%, but incur serious side effects. Several prescription drugs originally developed for other purposes, including bisphosphonates, statins, non-steroidal anti-inflammatory drugs, metformin, anti-hypertensives and retinoids, have shown anti-cancer activity in preclinical models. However, results of observational studies on CBC are sparse and inconsistent, with only statins demonstrating promise as preventive agents and a potential treatment option for ER-negative breast cancer patients.Conclusion: Future studies are needed to assess the effect of statins in risk reduction and to identify other drugs with chemopreventive potential against CBC. Eventually, efforts must be directed towards identifying those breast cancer patients likely to benefit most from specific preventive therapies.
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Affiliation(s)
- Annet Bens
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Rikke Langballe
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | | | | | - Søren Friis
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Unit of Statistics and Pharmacoepidemiology, Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Lene Mellemkjaer
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
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Daniel H, Christian W, Robin H, Lars S, Thomas M. Statin treatment after acute coronary syndrome: Adherence and reasons for non-adherence in a randomized controlled intervention trial. Sci Rep 2019; 9:12079. [PMID: 31427637 PMCID: PMC6700346 DOI: 10.1038/s41598-019-48540-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 08/07/2019] [Indexed: 12/11/2022] Open
Abstract
Studies of secondary prevention for cardiovascular disease show low fulfilment of guideline-recommended targets. This study explored whether nurse-led follow-up could increase adherence to statins over time and reasons for discontinuation. All patients admitted for acute coronary syndrome at Östersund hospital between 2010-2014 were screened for the randomized controlled NAILED-ACS trial. The trial comprises two groups, one with nurse-led annual follow-up and medical titration by telephone to reach set intervention targets and one with usual care. All discontinuations of statins were recorded prospectively for at least 36 months and categorized as avoidable or unavoidable. Kaplan-Meier estimates were conducted for first and permanent discontinuations. Predictors for discontinuation were analysed using multivariate Cox regression, statin type and mean LDL-C at end of follow-up. Female gender was a predictor for discontinuation. Allocation in the intervention group predicted increased risk for a first but decreased risk for permanent discontinuation. A nurse-led telemedical secondary prevention programme in a relatively unselected ACS cohort leads to increased adherence to statins over time, greater percentage on potent treatment and lower LDL-C compared to usual care. An initially increased tendency toward early discontinuation in the intervention group stresses the importance of a longer duration of structured follow-up.
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Affiliation(s)
- Huber Daniel
- Department of Public Health and Clinical Medicine, Unit of Research, Education and Development - Östersund, Umeå University, Östersund, Sweden.
| | - Wikén Christian
- Department of Public Health and Clinical Medicine, Unit of Research, Education and Development - Östersund, Umeå University, Östersund, Sweden
| | - Henriksson Robin
- Department of Public Health and Clinical Medicine, Unit of Research, Education and Development - Östersund, Umeå University, Östersund, Sweden
| | - Söderström Lars
- Unit of Research, Development and Education, Region Jämtland Härjedalen, Östersund Hospital, Östersund, Sweden
| | - Mooe Thomas
- Department of Public Health and Clinical Medicine, Unit of Research, Education and Development - Östersund, Umeå University, Östersund, Sweden
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19
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Koren MJ, Sabatine MS, Giugliano RP, Langslet G, Wiviott SD, Kassahun H, Ruzza A, Ma Y, Somaratne R, Raal FJ. Long-term Low-Density Lipoprotein Cholesterol-Lowering Efficacy, Persistence, and Safety of Evolocumab in Treatment of Hypercholesterolemia: Results Up to 4 Years From the Open-Label OSLER-1 Extension Study. JAMA Cardiol 2019; 2:598-607. [PMID: 28291870 DOI: 10.1001/jamacardio.2017.0747] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance The Open-Label Study of Long-term Evaluation Against LDL-C (OSLER-1) evaluated the durability of long-term efficacy and safety during long-term therapy with evolocumab, a monoclonal antibody against proprotein convertase subtilisin/kexin type 9 (PCSK9). Objective To determine whether LDL-C level reductions with evolocumab persist across different populations. Secondary objectives included assessment of adverse events, antidrug antibodies, and factors contributing to treatment discontinuation. Design, Setting, and Participants This ongoing, randomized open-label extension trial (OSLER-1) was conducted at 192 sites in 18 countries. A total of 1324 of 1666 patients randomized into 1 of 5 12-week double-blind phase 2 parent studies completed a parent study and chose to participate in OSLER-1; 1255 received 1 or more evolocumab doses. As of August 2016, 812 of 1324 (61%) had 208 weeks of follow-up. This current study was conducted from October 2011 to August 2016, with a data cutoff of August 26, 2016. Interventions During year 1, patients were randomized to evolocumab, 420 mg, plus standard of care (SOC) or SOC alone. After year 1, all patients continuing the study received evolocumab, 420 mg, plus SOC. Main Outcomes and Measures Lipids, safety, and tolerability every 12 weeks. A multivariate model identified factors associated with discontinuation of evolocumab. Results At parent study baseline, the mean (SD) age of the population was 57.1 (11.6) years, with 52.9% being women. The median LDL-C level was 133 mg/dL (to convert to millimoles per liter, multiply by 0.0259). After 52 weeks, evolocumab plus SOC was associated with a significant reduction in LDL-C level by 61% (95% CI, -63% to -60%) vs 2% (95% CI, -5% to -0.2%) with SOC alone (P < .001). At approximately 2, 3, and 4 years of study follow-up, the median LDL-C level was reduced by 59% (95% CI, -60% to -57%), 59% (95% CI, -61% to -58%), and 57% (95% CI, -59% to -55%), respectively, from parent study baseline. For patients receiving statin therapy unchanged from baseline, at week 208, the median LDL-C level reduction was 58%. No neutralizing antibodies to evolocumab were detected. The annualized incidence of new-onset diabetes was 4% in the SOC alone group and, adjusting for duration of evolocumab exposure, 2.8% in the evolocumab plus SOC group. Neurocognitive event rates were 0% (SOC alone) and 0.4% (evolocumab plus SOC). A total of 79% of patients persisted with evolocumab treatment, with a mean exposure duration of 44 months. Conclusions and Relevance In the longest clinical trial exposure to a PCSK9 inhibitor to date, evolocumab produced sustained reductions in LDL-C levels. The annual frequency of adverse events did not occur more frequently with cumulative exposure during open-label observation. Trial Registration clinicaltrials.gov Identifier: NCT01439880.
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Affiliation(s)
- Michael J Koren
- Jacksonville Center for Clinical Research, Jacksonville, Florida
| | - Marc S Sabatine
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts3Deputy Editor, JAMA Cardiology
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Stephen D Wiviott
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Yuhui Ma
- Amgen Inc, Thousand Oaks, California
| | | | - Frederick J Raal
- The Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Parktown, Johannesburg, South Africa
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20
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Leoni MC, Amelung L, Lieveld FI, van den Brink J, de Bruijne J, Arends JE, van Erpecum CP, van Erpecum KJ. Adherence to ursodeoxycholic acid therapy in patients with cholestatic and autoimmune liver disease. Clin Res Hepatol Gastroenterol 2019; 43:37-44. [PMID: 30219692 DOI: 10.1016/j.clinre.2018.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/08/2018] [Accepted: 08/21/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ursodeoxycholic acid (UDCA) is used for treatment of cholestatic liver diseases and may improve long-term outcome. Although treatment with this hydrophilic bile acid is virtually without side effects, medication adherence might be suboptimal due to patient misconceptions, compromising clinical outcome. Our aim was to evaluate adherence to UDCA in relation to patient beliefs about medicine and to identify potential predictors of poor adherence. METHODS Prospective open-label study recruiting patients in treatment with UDCA from April 2016 to March 2017. Adherence was assessed both by the Sensemedic dispenser and by patient-reported adherence, during 12 weeks. Good adherence was defined as ≥ 80% intake. Quality of life (by SF-36) and beliefs about medicine (by BMQ) were also assessed. RESULTS A total of 75 patients were enrolled (32% primary biliary cholangitis, 31% autoimmune hepatitis, 29% primary sclerosing cholangitis and 8% other conditions). Average adherence according to the medication dispenser was 92 ± 16% (range: 17-100). Eighty-nine percent of the patients exhibited good adherence and 11% poor adherence. According to the BMQ, 42% of all patients were accepting, 50% ambivalent, 8% indifferent and 0% skeptical to UDCA treatment. Poor adherence was associated with young age (P = 0.029) and male gender (P = 0.021). CONCLUSIONS Despite the excellent safety profile of UDCA, still a significant number of patients are poorly adherent. Young age and male sex are associated with poor adherence. Efforts should be made to identify patients with poor adherence and to improve their compliance to therapy.
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Affiliation(s)
- Maria Cristina Leoni
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht Affiliated to Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Infectious Diseases Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia, p.le Golgi 19, 27100 Pavia, Italy
| | - Linde Amelung
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht Affiliated to Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Department of Internal medicine and Infectious diseases, University Medical Center Utrecht Affiliated to Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Faydra I Lieveld
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht Affiliated to Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Janneke van den Brink
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht Affiliated to Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Joep de Bruijne
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht Affiliated to Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Joop E Arends
- Department of Internal medicine and Infectious diseases, University Medical Center Utrecht Affiliated to Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Carel-Peter van Erpecum
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht Affiliated to Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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Kawakami K, Wakatsuki T, Soejima A, Kobayashi K, Yokokawa T, Aoyama T, Suzuki K, Suenaga M, Yamaguchi K, Inoue A, Machida Y, Hama T. Factors Associated With Regorafenib Adherence With Metastatic Colorectal Cancer. Patient Prefer Adherence 2019; 13:1745-1750. [PMID: 31686792 PMCID: PMC6800560 DOI: 10.2147/ppa.s217835] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 09/21/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Regorafenib is an oral multikinase inhibitor for the treatment of metastatic colorectal cancer (mCRC). The clinical factors that may affect adherence to regorafenib remain unclear. The aim of this study was to evaluate adherence to regorafenib with mCRC and to identify factors that might affect adherence to regorafenib. METHODS A total of 108 consecutively enrolled Japanese patients with mCRC received regorafenib. Adherence was measured by pharmacists using pill counts and a self-reported treatment diary for patients at a pharmaceutical outpatient clinic. The median relative dose intensities of regorafenib and the factors adversely affecting adherence were retrospectively surveyed. Logistic regression analysis was then performed using patient socio-demographic factors and clinical factors. RESULTS A total of 96 patients were included in the analysis. The median adherence rate was 61.7% in the first cycle. The median relative dose intensity was 57.1%. The most common reason for non-adherence was a hand-foot-skin reaction (35.6%). On multivariate analysis, increased non-adherence to regorafenib was significantly associated with sex (female) [odds ratio (OR) = 4.36; 95% confidence interval (CI): 1.43-13.22, p = 0.01]. DISCUSSION Hand-foot-skin reactions and female sex were associated with lower adherence to regorafenib. Since these factors could be associated with lower adherence to regorafenib, it would be useful to consider these factors when assessing adherence.
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Affiliation(s)
- Kazuyoshi Kawakami
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-Ku, Tokyo135-8550, Japan
- Correspondence: Kazuyoshi Kawakami The Japanese Foundation for Cancer Research, Cancer Institute Hospital, Depatment of Pharmacy, 3-8-31 Ariake Koto-ku, Tokyo135-8550, Japan Email
| | - Takeru Wakatsuki
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-Ku, Tokyo135-8550, Japan
| | - Azusa Soejima
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-Ku, Tokyo135-8550, Japan
| | - Kazuo Kobayashi
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-Ku, Tokyo135-8550, Japan
| | - Takashi Yokokawa
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-Ku, Tokyo135-8550, Japan
| | - Takeshi Aoyama
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-Ku, Tokyo135-8550, Japan
| | - Kenichi Suzuki
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-Ku, Tokyo135-8550, Japan
| | - Mitsukuni Suenaga
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-Ku, Tokyo135-8550, Japan
| | - Kensei Yamaguchi
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-Ku, Tokyo135-8550, Japan
| | - Ayaka Inoue
- Section for Practical Education, Hoshi University School of Pharmacy and Pharmaceutical Sciences, Shinagawa-Ku, Tokyo142-8501, Japan
| | - Yoshiaki Machida
- Section for Practical Education, Hoshi University School of Pharmacy and Pharmaceutical Sciences, Shinagawa-Ku, Tokyo142-8501, Japan
| | - Toshihiro Hama
- Department of Pharmacy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto-Ku, Tokyo135-8550, Japan
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Bonaccio M, Di Castelnuovo A, Costanzo S, Persichillo M, De Curtis A, Cerletti C, Donati MB, de Gaetano G, Iacoviello L. Interaction between Mediterranean diet and statins on mortality risk in patients with cardiovascular disease: Findings from the Moli-sani Study. Int J Cardiol 2018; 276:248-254. [PMID: 30527993 DOI: 10.1016/j.ijcard.2018.11.117] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 11/07/2018] [Accepted: 11/23/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Statins are prescribed for patients with cardiovascular disease (CVD), along with the recommendation of adopting healthy diets. We evaluated the independent and the combined effect of statins and Mediterranean diet (MD) towards mortality risk in patients with previous CVD by using real-life data from a population-based prospective cohort. METHODS Longitudinal analysis on 1180 subjects (mean age 67.7 ± 10) with prior CVD at enrollment in the Moli-sani Study and followed up for 7.9 y (median). Adherence to MD was appraised by a Mediterranean diet score. Hazard ratios (HR) with 95% confidence intervals (95% CI) were calculated by multivariable Cox regression and competing risk models. RESULTS Multivariable risk estimates associated with a 2-point increase in MD score were 0.84 (95% CI 0.70-1.00), 0.77 (0.61-0.97) and 0.70 (0.52-0.93) for overall, cardiovascular and coronary artery disease (CAD)/cerebrovascular deaths, respectively. Statins were not associated with death risk. Subjects combining statins and average-high adherence to MD had much lower than expected risk of cardiovascular and CAD/cerebrovascular mortality (p for interaction = 0.045 and 0.0015, respectively) as compared to those neither using statins nor having average-high MD. The combination of average-high MD and statins was associated in a likely synergistic way with reduced low-grade inflammation, but not with blood cholesterol. CONCLUSIONS MD lowered the risk of all-cause, cardiovascular and CAD/cerebrovascular mortality CVD patients, net of statins. In the same population, statins reduced CVD death risk only in combination with MD. Low-grade inflammation, rather than lipids, is likely to be on the pathway of the interaction between MD and statins towards mortality risk.
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Affiliation(s)
- Marialaura Bonaccio
- Department of Epidemiology and Prevention, IRCCS Neuromed, Via dell'Elettronica, 86077 Pozzilli, IS, Italy.
| | - Augusto Di Castelnuovo
- Department of Epidemiology and Prevention, IRCCS Neuromed, Via dell'Elettronica, 86077 Pozzilli, IS, Italy
| | - Simona Costanzo
- Department of Epidemiology and Prevention, IRCCS Neuromed, Via dell'Elettronica, 86077 Pozzilli, IS, Italy
| | - Mariarosaria Persichillo
- Department of Epidemiology and Prevention, IRCCS Neuromed, Via dell'Elettronica, 86077 Pozzilli, IS, Italy
| | - Amalia De Curtis
- Department of Epidemiology and Prevention, IRCCS Neuromed, Via dell'Elettronica, 86077 Pozzilli, IS, Italy
| | - Chiara Cerletti
- Department of Epidemiology and Prevention, IRCCS Neuromed, Via dell'Elettronica, 86077 Pozzilli, IS, Italy
| | - Maria Benedetta Donati
- Department of Epidemiology and Prevention, IRCCS Neuromed, Via dell'Elettronica, 86077 Pozzilli, IS, Italy
| | - Giovanni de Gaetano
- Department of Epidemiology and Prevention, IRCCS Neuromed, Via dell'Elettronica, 86077 Pozzilli, IS, Italy
| | - Licia Iacoviello
- Department of Epidemiology and Prevention, IRCCS Neuromed, Via dell'Elettronica, 86077 Pozzilli, IS, Italy; Department of Medicine and Surgery, Research Center in Epidemiology and Preventive Medicine (EPIMED), University of Insubria, 21100 Varese, Italy
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Byrne JL, Dallosso HM, Rogers S, Gray LJ, Waheed G, Patel P, Gupta P, Doherty Y, Davies M, Khunti K. The Ready to Reduce Risk (3R) Study for a Group Educational Intervention With Telephone and Text Messaging Support to Improve Medication Adherence for the Primary Prevention of Cardiovascular Disease: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2018; 7:e11289. [PMID: 30425027 PMCID: PMC6256101 DOI: 10.2196/11289] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/09/2018] [Accepted: 08/20/2018] [Indexed: 01/23/2023] Open
Abstract
Background Poor adherence to cardiovascular medications is associated with worse clinical outcomes. Evidence for effective education interventions that address medication adherence for the primary prevention of cardiovascular disease is lacking. The Ready to Reduce Risk (3R) study aims to investigate whether a complex intervention, involving group education plus telephone and text messaging follow-up support, can improve medication adherence and reduce cardiovascular risk. Objective This protocol paper details the design and rationale for the development of the 3R intervention and the study methods used. Methods This is an open and pragmatic randomized controlled trial with 12 months of follow-up. We recruited participants from primary care and randomly assigned them at a 1:1 frequency, stratified by sex and age, to either a control group (usual care from a general practitioner) or an intervention group involving 2 facilitated group education sessions with telephone and text messaging follow-up support, with a theoretical underpinning and using recognized behavioral change techniques. The primary outcome was medication adherence to statins. The primary measure was an objective, novel, urine-based biochemical measure of medication adherence. We also used the 8-item Morisky Medication Adherence Scale to assess medication adherence. Secondary outcomes were changes in total cholesterol, blood pressure, high-density lipoprotein, total cholesterol to high-density lipoprotein ratio, body mass index, waist to hip ratio, waist circumference, smoking behavior, physical activity, fruit and vegetable intake, patient activation level, quality of life, health status, health and medication beliefs, and overall cardiovascular disease risk score. We also considered process outcomes relating to acceptability and feasibility of the 3R intervention. Results We recruited 212 participants between May 2015 and March 2017. The 12-month follow-up data collection clinics were completed in April 2018, and data analysis will commence once all study data have been collected and verified. Conclusions This study will identify a potentially clinically useful and effective educational intervention for the primary prevention of cardiovascular disease. Medication adherence to statins is being assessed using a novel urine assay as an objective measure, in conjunction with other validated measures. Trial Registration International Standard Randomized Controlled Trial Number ISRCTN16863160; http://www.isrctn.com/ISRCTN16863160 (Archived by WebCite at http://www.webcitation.org/734PqfdQw) International Registered Report Identifier (IRRID) DERR1-10.2196/11289
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Affiliation(s)
- Jo L Byrne
- Leicester Diabetes Centre, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
| | - Helen M Dallosso
- Leicester Diabetes Centre, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
| | - Stephen Rogers
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom.,Innovation and Research Unit, Northamptonshire Healthcare Foundation Trust, Northampton, United Kingdom
| | - Laura J Gray
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Ghazala Waheed
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Prashanth Patel
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,Department of Clinical Pathology and Metabolic Sciences, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
| | - Pankaj Gupta
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,Department of Clinical Pathology and Metabolic Sciences, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
| | - Yvonne Doherty
- Leicester Diabetes Centre, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom.,York Diabetes Centre, York Teaching Hospital National Health Service Foundation Trust, York, United Kingdom
| | - Melanie Davies
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
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Booth JN, Colantonio LD, Rosenson RS, Safford MM, Chen L, Kilgore ML, Brown TM, Taylor B, Dent R, Monda KL, Muntner P, Levitan EB. Healthcare Utilization and Statin Re-Initiation Among Medicare Beneficiaries With a History of Myocardial Infarction. J Am Heart Assoc 2018; 7:JAHA.117.008462. [PMID: 29739799 PMCID: PMC6015328 DOI: 10.1161/jaha.117.008462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Contact with the healthcare system represents an opportunity for individuals who discontinue statins to re‐initiate treatment. To help identify opportunities for healthcare providers to emphasize the risk‐lowering benefits accrued through restarting statins, we determined the types of healthcare utilization associated with statin re‐initiation among patients with history of a myocardial infarction. Methods and Results Medicare beneficiaries with a statin pharmacy fill claim within 30 days of hospital discharge for a myocardial infarction in 2007 to 2012 (n=158 795) were followed for 182 days postdischarge to identify treatment discontinuation, defined as 60 continuous days without statins (n=24 461). Re‐initiation was defined as a statin fill within 365 days of the discontinuation date (n=13 136). Using a case‐crossover study design and each beneficiary as their own control, healthcare utilization during 0 to 14 days before statin re‐initiation (case period) was compared with healthcare utilization 30 to 44 days before statin re‐initiation (control period). The mean age of beneficiaries was 75.4 years; 52.8% were women and 81.9% were white. For routine healthcare utilization, the odds ratio (95% confidence interval) for statin re‐initiation associated with lipid panel testing was 2.65 (1.93–3.65), outpatient primary care was 1.31 (1.23–1.40), and outpatient cardiologist care was 1.38 (1.28–1.50). For acute healthcare utilization, the odds ratio (95% confidence interval) for statin re‐initiation associated with emergency department visits was 1.77 (1.31–2.40), coronary heart disease (CHD) hospitalizations was 3.16 (2.41–4.14) and non–coronary heart disease hospitalizations was 1.73 (1.49–2.01). Conclusions The weaker association of routine versus acute healthcare utilization with statin re‐initiation suggests missed opportunities to reinforce the importance of statin therapy for secondary prevention.
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Affiliation(s)
- John N Booth
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Robert S Rosenson
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Ligong Chen
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Meredith L Kilgore
- Department of Health Care Organization and Policy, University of Alabama at Birmingham, AL
| | - Todd M Brown
- Department of Medicine, University of Alabama at Birmingham, AL
| | - Benjamin Taylor
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA
| | - Ricardo Dent
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA
| | - Keri L Monda
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
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Zhang H, Plutzky J, Ge W, Shubina M, Turchin A. Predictors of a successful statin reattempt after an adverse reaction. J Clin Lipidol 2018; 12:643-651. [DOI: 10.1016/j.jacl.2018.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 01/31/2018] [Accepted: 02/08/2018] [Indexed: 11/27/2022]
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Fairman KA, Davis LE, Sclar DA. Real-world use of PCSK-9 inhibitors by early adopters: cardiovascular risk factors, statin co-treatment, and short-term adherence in routine clinical practice. Ther Clin Risk Manag 2017; 13:957-965. [PMID: 28831261 PMCID: PMC5548274 DOI: 10.2147/tcrm.s143008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Inconsistency of real-world medication use with labeled indications may affect cost and clinical value of pharmacotherapy. PCSK-9 inhibitors are labeled in the US for use with statins to reduce low-density lipoprotein cholesterol in patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia (FH). Objective To assess consistency with labeled indications and treatment persistency for early (first 5 post-launch months) adopters of PCSK-9 inhibitor pharmacotherapy. Methods Retrospective analysis of commercially insured cohorts derived from the Truven Health MarketScan® database was performed. Subjects were aged 18–64 years, initiated PCSK-9 inhibitor or highest-intensity statin (rosuvastatin 40 mg/day or atorvastatin 80 mg/day) pharmacotherapy from August to December 2015, and were enrolled throughout 2015 and during separate baseline (pre-treatment) periods of 6 and 18 months. Baseline ASCVD, FH, and ASCVD events (myocardial infarction, transient ischemic attack, and cerebrovascular occlusion) were measured. Persistency was measured through December 2015 for subcohorts of patients initiating treatment from August to September 2015. Results Baseline disease rates were higher for patients treated with PCSK-9 inhibitors (n=390) compared with highest-intensity statins (n=26,306): ASCVD (68.5% vs 33.4%, respectively); FH (39.7% vs 15.5%); both P<0.001. In 18 months pre-treatment, 35.6% of PCSK-9 inhibitor-treated patients had ≥1 ASCVD event, and 87.9% had a labeled indication. Rates of 60-day nonpersistency for PCSK-9 inhibitors and highest-intensity statins were 33.3% and 39.8%, respectively (P=0.207). During PCSK-9 inhibitor pharmacotherapy, 33.8% of patients had evidence of statin supply and, of those initiating treatment from August to September, 40.9% filled ≥1 statin prescription. Of those with sustained pre-treatment statin use, 34.8% had no statin supply during PCSK-9 inhibitor pharmacotherapy. Conclusion Among early-adopting PCSK-9 inhibitor-treated patients, the off-label diagnosis rate was 12%; a majority lacked statin co-treatment; and one third filled prescriptions for ≤60 days. Inconsistency with labeled uses may reflect prescriber/patient decisions, health-insurance coverage determinations, or statin intolerance not reported on claims.
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Affiliation(s)
- Kathleen A Fairman
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University-Glendale, Glendale, AZ, USA
| | - Lindsay E Davis
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University-Glendale, Glendale, AZ, USA
| | - David A Sclar
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University-Glendale, Glendale, AZ, USA
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Deshpande S, Quek RGW, Forbes CA, de Kock S, Kleijnen J, Gandra SR, Simpson RJ. A systematic review to assess adherence and persistence with statins. Curr Med Res Opin 2017; 33:769-778. [PMID: 28076703 DOI: 10.1080/03007995.2017.1281109] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To identify and assess studies published over a 10 year period up to February 2016 which measure adherence or persistence with statins, to summarize their methods, strengths and weaknesses and to summarize evidence linking statin adherence/persistence with risk of cardiovascular events. METHODS Electronic databases and abstracts from four major cardiovascular disease conferences were searched from January 2005 to February 2016. The study selection process was performed by two reviewers working independently. Studies were included if they reported data regarding patient adherence or persistence with statins in adults with primary hypercholesterolemia, using any type of study design or length of follow-up. One reviewer extracted the study data and assessed study quality, which was checked by a second reviewer independently. Given the heterogeneity between the included studies a narrative critique and summary is presented. RESULTS We report on 84 real world studies which aimed to assess adherence or persistence with statins. The majority of studies concluded that good adherence/persistence was associated with reduction in cardiovascular events and mortality. In two studies high intensity statin regimens were associated with poorer patient adherence when compared to low intensity statins. Adherence and persistence with statin therapy also has an impact on hospitalization costs and other cardiovascular disease (CVD) related costs. CONCLUSIONS Adherence and persistence are associated with a reduction in CVD events and mortality. There was limited evidence to suggest that high intensity statin regimens are associated with poorer treatment adherence when compared to lower intensity regimens. Hence, more robust studies are required to establish this association. As recommended by the 2013 ACC/AHA, 2016 ESC and several other clinical guidelines, clinicians and pharmacy managers should regularly monitor statin therapy adherence.
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Affiliation(s)
| | - Ruben G W Quek
- b Amgen Inc., One Amgen Center Drive , Thousand Oaks , CA , USA
| | - Carol A Forbes
- a Kleijnen Systematic Reviews Ltd , York , United Kingdom
| | | | - Jos Kleijnen
- a Kleijnen Systematic Reviews Ltd , York , United Kingdom
- c School for Public Health and Primary Care , Maastricht University , Maastricht , The Netherlands
| | | | - Ross J Simpson
- d UNC Hospitals Heart and Vascular Center at Meadowmont , Chapel Hill , NC , USA
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Can We Identify Minority Patients at Risk of Nonadherence to Antiplatelet Medication at the Time of Coronary Stent Placement? J Cardiovasc Nurs 2017; 32:522-529. [PMID: 28060084 DOI: 10.1097/jcn.0000000000000387] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lack of medication adherence is associated with significant morbidity and mortality, particularly among minorities. We aim to identify predictors of nonadherence to antiplatelet medications at the time of percutaneous coronary intervention (PCI) with stent among African American and Hispanic patients. METHODS We used data collected for a randomized clinical trial that recruited 452 minority patients from a large US health insurance organization in 2010 post-PCI to compare telephone-based motivational interviewing by trained nurses with an educational video. The primary outcome was 12-month adherence to antiplatelet medications measured by the claims-based medication possession ratio (MPR). Adequate adherence was defined as an MPR of 0.80 or higher. RESULTS More than half of the sample (age, 69.52 ± 8.8 years) was male (57%) and Hispanic (57%). Most (78%) had a median income below $30 000 and 22% completed high school or higher. Univariate analyses revealed that symptoms of depression (<.01) and not having a spouse (P = .03) were associated with inadequate adherence. In multivariate analysis, baseline self-reported adherence (1.4; 95% confidence interval [CI], 1.05-1.89), depressive symptoms (0.49; 95% CI, 0.7-0.90), comorbidity (0.89; 95% CI, 0.80-0.98), and telephone-based motivational interviewing by trained nurses (3.5; 95% CI, 1.9-2.70) were associated with adherence. CONCLUSIONS Having multiple comorbidities, depression, suboptimal adherence to medications, and low English proficiency at the time of PCI increase the risk of poor 12-month adherence to antiplatelets among minorities. Identifying these risk factors can guide PCI therapy and the use of evidence-based strategies to improve long-term adherence.
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Degli Esposti L, Sangiorgi D, Buda S, Degli Esposti E, Scaglione F. Therapy discontinuation or substitution in patients with cardiovascular disease, switching among different products of the same off-patent active substance: a 'real-world' retrospective cohort study. BMJ Open 2016; 6:e012003. [PMID: 27807083 PMCID: PMC5129038 DOI: 10.1136/bmjopen-2016-012003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The present study investigated the effects of switching to different products of the same off-patent active substance (brand name or generic) on therapy discontinuation or substitution with another molecule of the same class, in patients with cardiovascular disease treated with statins and antihypertensives in a 'real-world' setting. DESIGN A retrospective cohort study in a 'real-world' setting. SETTING Analysis of data performed by integrating administrative databases that included approximately two million individuals who are assisted by the National Health System from three Local Health Units located in three different regions of Italy. PARTICIPANTS All patients aged ≥18 years with at least one prescription of simvastatin, ramipril or amlodipine in the period 1 January to 31 December 2010 were included and followed up for 2 years. MAIN OUTCOME MEASURES Prescription refills occurring during follow-up were evaluated. Frequency of discontinuation of therapy or substitution with another molecule of the same class (eg, from simvastatin to a different statin) during follow-up was identified. RESULTS During follow-up, therapy discontinuation or substitution was found to be more frequent in patients switching to a different product of the same active substance compared with non-switching patients (11.5% vs 10.8% and 22.2% vs 20.8% (p=0.002), respectively, in the simvastatin group; 4.0% vs 3.5% and 24.6% vs 22.7% (p<0.001), respectively, in the amlodipine group). In the ramipril group, 8% of patients undertook a therapy substitution to another molecule; no trend towards a lower percentage of substitution was observed in the non-switching group, while 18% of patients discontinued treatment, with a significant difference in favour of patients not switching. These findings were partially confirmed by multivariate analysis. CONCLUSIONS Switches among products of the same active substance are quite common in patients with cardiovascular disease. Our study suggests that switching may expose patients to a higher risk of therapy discontinuation or substitution.
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Affiliation(s)
| | - Diego Sangiorgi
- CliCon S.r.l. Health, Economics and Outcomes Research, Ravenna, Italy
| | - Stefano Buda
- CliCon S.r.l. Health, Economics and Outcomes Research, Ravenna, Italy
| | | | - Francesco Scaglione
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
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van Vlerken LG, Lieveld FI, van Meer S, Koek GH, van Nieuwkerk KMJ, Friederich P, Arends JE, Siersema PD, Burger DM, van Erpecum KJ. Adherence to ribavirin in chronic hepatitis C patients on antiviral treatment: Results from a randomized controlled trial using real-time medication monitoring. Clin Res Hepatol Gastroenterol 2016; 40:622-630. [PMID: 26867863 DOI: 10.1016/j.clinre.2015.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 12/17/2015] [Accepted: 12/25/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Adherence is essential in antiviral therapy for chronic hepatitis C. We investigated the effect of real-time medication monitoring on adherence to ribavirin. METHODS In this randomized controlled trial, patients in the intervention group received a medication dispenser that monitored ribavirin intake real-time during 24 weeks PEG-interferon/ribavirin±boceprevir or telaprevir. Patients in the control group received standard-of-care. Adherence was also measured by pill count. RESULTS Seventy-two patients were assigned to either intervention (n=35) or control groups (n=37). Median adherence by pill count was 96% (range: 43%-100%) with 30 (94%) of patients exhibiting≥80% adherence. Perfect adherence (i.e. 100%) was similar in intervention and control groups: 22 (85%) vs. 15 (75%) (P=0.47). Adherences by real-time medication monitoring and by pill count did not correlate (R=0.19, P=0.36). No predictors of poor adherence could be identified. Ribavirin trough levels after 8 weeks (median: 2.4 vs. 2.7mg/L, P=0.30) and 24 weeks (median: 3.0 vs. 3.0mg/L, P=0.69), and virological responses did not differ between intervention and control groups. CONCLUSIONS Adherence to ribavirin during PEG-interferon containing therapy in chronic hepatitis C is high. Real-time medication monitoring did not influence adherence to ribavirin, plasma ribavirin levels or virological responses.
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Affiliation(s)
- Lotte G van Vlerken
- Department of Gastroenterology and Hepatology, University Medical Center of Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Faydra I Lieveld
- Department of Gastroenterology and Hepatology, University Medical Center of Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands; Department of Internal Medicine and Infectious Diseases, University Medical Center of Utrecht, Utrecht, The Netherlands
| | - Suzanne van Meer
- Department of Gastroenterology and Hepatology, University Medical Center of Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Ger H Koek
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Karin M J van Nieuwkerk
- Department of Gastroenterology and Hepatology, Free University Medical Center, Amsterdam, The Netherlands
| | - Pieter Friederich
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Joop E Arends
- Department of Internal Medicine and Infectious Diseases, University Medical Center of Utrecht, Utrecht, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center of Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands; Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Center of Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
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Abstract
Despite encouraging advances in prevention and treatment of atherothrombosis, cardiovascular disease (CVD) remains a major cause of deaths and disability worldwide and will continue to grow mainly due to the increase in incidence in low and middle income countries (LMIC). In Europe and the United States of America (USA), coronary heart disease (CHD) mortality rates have decreased since the mid-1990s due to improvements in acute care, however the prevalence of CHD is increasing largely in part due to the overall aging of the population, increased prevalence of cardiovascular (CV) risk factors, and improved survival of patients after a CV event. Data from clinical trials has consistently proven the efficacy of pharmacologic interventions with aspirin, statins, and blood pressure (BP)-lowering agents in reducing the risk of CV events and total mortality in the ever growing pool of patients in secondary prevention. However, large gaps between indicated therapy and prescribed medication can be observed worldwide, with very low rates of use of effective therapies in LMIC countries. Adherence to medication is very poor in chronic patients, especially those treated with multiple pharmacologic agents, and has been directly correlated to a greater incidence of recurrent CV events and increase in direct and indirect healthcare costs. In this article, we review the global burden of CV disease, status of secondary prevention therapy and major barriers for treatment adherence.
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Affiliation(s)
- Sameer Bansilal
- Mount Sinai Cardiovascular Institute, New York, USA; Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, Madrid, Spain
| | - José M Castellano
- Mount Sinai Cardiovascular Institute, New York, USA; Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, Madrid, Spain; HM Hospitales, Hospital Universitario Montepríncipe, Madrid, Spain
| | - Valentín Fuster
- Mount Sinai Cardiovascular Institute, New York, USA; Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, Madrid, Spain.
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Hofmann E, Faller N, Limacher A, Méan M, Tritschler T, Rodondi N, Aujesky D. Educational Level, Anticoagulation Quality, and Clinical Outcomes in Elderly Patients with Acute Venous Thromboembolism: A Prospective Cohort Study. PLoS One 2016; 11:e0162108. [PMID: 27606617 PMCID: PMC5015908 DOI: 10.1371/journal.pone.0162108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 08/17/2016] [Indexed: 12/05/2022] Open
Abstract
Whether the level of education is associated with anticoagulation quality and clinical outcomes in patients with acute venous thromboembolism (VTE) is uncertain. We thus aimed to investigate the association between educational level and anticoagulation quality and clinical outcomes in elderly patients with acute VTE. We studied 817 patients aged ≥65 years with acute VTE from a Swiss prospective multicenter cohort study (09/2009-12/2013). We defined three educational levels: 1) less than high school, 2) high school, and 3) post-secondary degree. The primary outcome was the anticoagulation quality, expressed as the percentage of time spent in the therapeutic INR range (TTR). Secondary outcomes were the time to a first recurrent VTE and major bleeding. We adjusted for potential confounders and periods of anticoagulation. Overall, 56% of patients had less than high school, 25% a high school degree, and 18% a post-secondary degree. The mean percentage of TTR was similar across educational levels (less than high school, 61%; high school, 64%; and post-secondary, 63%; P = 0.36). Within three years of follow-up, patients with less than high school, high school, and a post-secondary degree had a cumulative incidence of recurrent VTE of 14.2%, 12.9%, and 16.4%, and a cumulative incidence of major bleeding of 13.3%, 15.1%, and 15.4%, respectively. After adjustment, educational level was neither associated with anticoagulation quality nor with recurrent VTE or major bleeding. In elderly patients with VTE, we did not find an association between educational level and anticoagulation quality or clinical outcomes.
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Affiliation(s)
- Eveline Hofmann
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Faller
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
| | - Andreas Limacher
- Clinical Trials Unit Bern, Department of Clinical Research, and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Marie Méan
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
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Rash JA, Campbell DJT, Tonelli M, Campbell TS. A systematic review of interventions to improve adherence to statin medication: What do we know about what works? Prev Med 2016; 90:155-69. [PMID: 27413005 DOI: 10.1016/j.ypmed.2016.07.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/01/2016] [Accepted: 07/08/2016] [Indexed: 11/27/2022]
Abstract
Suboptimal adherence to statin medication is common and leads to serious negative health consequences but may respond to intervention. This review evaluated the effectiveness of interventions intended to improve adherence to statin medication. Data sources included peer-reviewed publications from Cochrane Register of Randomized Controlled Trials (RCTs), PubMed, CINAHL, and EMBase indexed between 01 October 2008 and 18 October 2015 and studies from reference lists and technical experts. RCTs that evaluated an intervention targeting adherence to self-administered statin medication for primary or secondary prevention were eligible. Two investigators independently reviewed trials, extracted data, and evaluated risk of bias. Twenty-nine RCTs reporting on 39,769 patients met inclusion. Identified RCTs exhibited methodological weaknesses: all but one failed to set inclusion parameters for medication adherence; nearly half lacked sufficient power to detect meaningful effects; and the majority had a risk of bias. Interventions were categorized into five classes (simplification of regimen, prescription cost coverage, reminders, education and information, and multi-faceted) and effects were pooled within each class. Prescription cost coverage, Hedges' g=0.15, 95%CI [0.11:0.21], simplification of drug regimen, Hedges' g=0.38, 95%CI [0.22:0.55], the provision of education, Hedges' g=0.19, 95%CI [0.01:0.37], and the use of multi-faceted interventions, Hedges' g=0.16, 95%CI [0.05:0.27], had small positive effects on statin adherence relative to usual care and reminders were promising, Hedges' g=0.0.27, 95%CI [-0.05:0.60]. In conclusion, there are some successful interventions to improve adherence to statin medication but the effects are small and additional methodologically rigorous trials are needed.
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Affiliation(s)
- Joshua A Rash
- Department of Psychology, University of Calgary, 2500 University Drive N.W., Calgary, AB T2N 1N4, Canada
| | - David J T Campbell
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr N.W., Calgary, AB T2N 1N4, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr N.W., Calgary, AB T2N 1N4, Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr N.W., Calgary, AB T2N 1N4, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr N.W., Calgary, AB T2N 1N4, Canada
| | - Tavis S Campbell
- Department of Psychology, University of Calgary, 2500 University Drive N.W., Calgary, AB T2N 1N4, Canada.
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Korhonen MJ, Pentti J, Hartikainen J, Kivimäki M, Vahtera J. Somatic symptoms of anxiety and nonadherence to statin therapy. Int J Cardiol 2016; 214:493-9. [DOI: 10.1016/j.ijcard.2016.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/02/2016] [Indexed: 12/22/2022]
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Halava H, Huupponen R, Pentti J, Kivimäki M, Vahtera J. Predictors of first-year statin medication discontinuation: A cohort study. J Clin Lipidol 2016; 10:987-995. [PMID: 27578131 PMCID: PMC5012887 DOI: 10.1016/j.jacl.2016.04.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 04/26/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The discontinuation of statin medication is associated with an increased risk of cardiovascular and cerebrovascular events and, among high-risk patients, all-cause mortality, but the reasons for discontinuation among statin initiators in clinical practice are poorly understood. OBJECTIVE To examine factors predicting the early discontinuation of statin therapy. METHODS In this prospective cohort study, participants with baseline measurements before the initiation of statin treatment were linked to national registers and followed for the discontinuation of statins during the first year of treatment (no filled prescriptions after statin initiation within the subsequent 12 months). RESULTS Of all the 9285 statin initiators, 12% (n = 1142) were discontinuers. Obesity, overweight, vascular comorbidities, and older age were independently associated with a reduced risk of discontinuation [odds ratios (OR) = 0.82 (95% confidence interval [CI], 0.69-0.99), 0.85 (95% CI, 0.73-0.98), 0.80 (95% CI, 0.68-0.93), and 0.82 (95% CI, 0.68-0.99), respectively]. In contrast, high-patient cost-sharing was associated with an increased odds (OR = 1.29; 95% CI, 1.03-1.62) for discontinuation. The only significant difference between the sexes (P = .002) was observed among the participants with risky alcohol use, which was associated with a decreased odds for discontinuation among the men (OR = 0.69; 95% CI, 0.49-0.98) and an increased odds among the women (OR = 1.28; 95% CI, 1.02-1.62). CONCLUSIONS The discontinuation of statin therapy during the first year after initiation is common. Lowering out-of-pocket expenditures and focusing on low-risk patient groups and women with risky alcohol use could help maintain the continuation of medication.
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Affiliation(s)
- Heli Halava
- Department of Public Health, University of Turku, Turku, Finland.
| | - Risto Huupponen
- Department of Pharmacology, Drug Development and Therapeutics, University of Turku, Turku, Finland; Tykslab, Turku University Hospital, Turku, Finland
| | - Jaana Pentti
- Finnish Institute of Occupational Health, Turku, Finland
| | - Mika Kivimäki
- Department of Epidemiology and Public Health, University College of London, London, UK; Department of Public Health, Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jussi Vahtera
- Department of Public Health, University of Turku, Turku, Finland; Finnish Institute of Occupational Health, Turku, Finland; Turku University Hospital, Turku, Finland
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Rash JA, Lavoie KL, Sigal RJ, Campbell DJT, Manns BJ, Tonelli M, Campbell TS. The OPTIMIZE trial: Rationale and design of a randomized controlled trial of motivational enhancement therapy to improve adherence to statin medication. Contemp Clin Trials 2016; 49:47-56. [PMID: 27282119 DOI: 10.1016/j.cct.2016.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 05/30/2016] [Accepted: 06/04/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Statins are a class of medications that are particularly effective for lowering cholesterol and reducing cardiovascular morbidity and mortality. Despite a range of benefits, non-adherence to statin medication is prevalent with 50% to 75% of patients failing to adhere to treatment within the first 2-years. A previous review on interventions to improve adherence to cholesterol lowering medication concluded that rigorous trials were needed with emphasis on the patient's perspective and shared decision making. Motivational interviewing (MInt) is a promising patient-centered approach for improving adherence in patients with chronic diseases. This manuscript describes the rational and design of a randomized controlled trial (RCT) testing the efficacy of MInt in improving adherence to statin medication. METHODS Patients filling their first statin prescription will be recruited to complete a 6-month observation run-in period (phase-1) after which medication possession ratio (MPR) will be assessed. Patients meeting criteria for non-adherence (MPR≤60%) will be invited to participate in the trial. 336 non-adherent new statin users will undergo a fasting lipid panel, complete baseline questionnaires, and be randomly allocated to receive four sessions of adherence education delivered using MInt (EdMInt) or to an education control (EC) delivered at 3-month intervals. Final assessments will occur 12-months after the first EdMInt or EC session. The primary outcome is change in MPR adherence to statin medication from baseline to 12-months. Secondary outcomes include within-patient change in self-reported medication adherence, stage of change and self-efficacy for medication adherence, motivation to adhere to statin medication, and lipid profile.
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Affiliation(s)
- Joshua A Rash
- Department of Psychology, University of Calgary, 2500 University Drive N.W., Calgary, AB, Canada
| | - Kim L Lavoie
- Department of Psychology, University of Quebec at Montreal (UQAM), CP 8888, Succursale Centre-Ville, Montreal, QC, H3C 3P8, Canada; Montreal Behavioral Medicine Centre (MBMC), Research Centre, Hopital du Sacre-Coeur de Montreal, 5400 Gouin Blvd West, J-3145, Montreal, QC, H2J 1C5, Canada
| | - Ronald J Sigal
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David J T Campbell
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Braden J Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tavis S Campbell
- Department of Psychology, University of Calgary, 2500 University Drive N.W., Calgary, AB, Canada.
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Lipid lowering drug therapy in patients with coronary heart disease from 24 European countries – Findings from the EUROASPIRE IV survey. Atherosclerosis 2016; 246:243-50. [DOI: 10.1016/j.atherosclerosis.2016.01.018] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/11/2016] [Accepted: 01/11/2016] [Indexed: 12/11/2022]
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Affiliation(s)
- J. David Spence
- Stroke Prevention & Atherosclerosis Research CentreRobarts Research InstituteWestern UniversityLondonOntarioCanada
- Division of Clinical PharmacologyDepartment of MedicineWestern UniversityLondonOntarioCanada
| | - George K. Dresser
- Division of Clinical PharmacologyDepartment of MedicineWestern UniversityLondonOntarioCanada
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WITHDRAWN: Global burden of CVD: Focus on secondary prevention of cardiovascular disease. Int J Cardiol 2016. [DOI: 10.1016/j.ijcard.2016.01.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Citarella A, Linder M, Kieler H, Berglind IA, Sundström A, Wettermark B, Andersen M. Influence of baseline low-density lipoprotein cholesterol values on statin therapy persistence. Eur J Clin Pharmacol 2015; 72:349-57. [DOI: 10.1007/s00228-015-1996-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 12/02/2015] [Indexed: 11/24/2022]
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Casula M, Tragni E, Piccinelli R, Zambon A, De Fendi L, Scotti L, Corrao G, Gambera M, Catapano AL, Filippi A. A simple informative intervention in primary care increases statin adherence. Eur J Clin Pharmacol 2015; 72:227-34. [PMID: 26563188 DOI: 10.1007/s00228-015-1975-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/30/2015] [Indexed: 02/08/2023]
Abstract
PURPOSE To assess the effectiveness of an informative intervention on general practitioners aimed at improving patients' adherence to statin therapy. METHODS In the local health unit (LHU) of Bergamo, Lombardy (Italy), each general practitioner received a synthetic scientific document on dyslipidaemia and statins and aggregated data on adherence in 2006 for his/her patients compared to the means in the LHU and in his/her working district. Furthermore, a sample of seven districts received also a table of adherence levels for single patients. Patient's level data were retrieved from the health care utilisation databases of the LHU. Adherence parameters (proportion of patients with only one prescription, medication possession ratio [MPR] and proportion of non-persistent patients) were assessed after 1 year of follow-up. RESULTS Overall, 5833 and 4788 new statin users were enrolled before and after the intervention, respectively. The percentage of patients with only one prescription decreased from 28.0 to 23.9 % (p < 0.001). MPR increased from 70.3 to 76.0 % (p < 0.001), and proportion of patients with MPR ≥ 80 % increased from 45.4 to 56.4 % (p < 0.001). The persistence also showed an improvement, both in terms of decreasing proportion of non-persistent (from 51.9 to 41.4 %, p < 0.001) and of increasing duration of continued therapy (from 235 to 264 mean days of persistent therapy, p < 0.001). There were not significant differences between the two types of intervention. CONCLUSIONS This intervention resulted in an overall improvement of the short-term adherence to therapy. This tool can be replicated in other local contexts and with other chronic therapies.
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Affiliation(s)
- Manuela Casula
- Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Via Balzaretti 9, 20133, Milan, Italy.
| | - Elena Tragni
- Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Via Balzaretti 9, 20133, Milan, Italy
| | - Rossana Piccinelli
- Local Pharmaceutical Service, LHU of Bergamo, via Gallicciolli 4, 24121, Bergamo, Italy
| | - Antonella Zambon
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Via Bicocca degli Arcimboldi 8, 20126, Milan, Italy
| | - Luisa De Fendi
- Local Pharmaceutical Service, LHU of Bergamo, via Gallicciolli 4, 24121, Bergamo, Italy
| | - Lorenza Scotti
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Via Bicocca degli Arcimboldi 8, 20126, Milan, Italy
| | - Giovanni Corrao
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Via Bicocca degli Arcimboldi 8, 20126, Milan, Italy
| | - Marco Gambera
- Local Pharmaceutical Service, LHU of Bergamo, via Gallicciolli 4, 24121, Bergamo, Italy
| | - Alberico Luigi Catapano
- Epidemiology and Preventive Pharmacology Centre (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Via Balzaretti 9, 20133, Milan, Italy.,IRCCS MultiMedica, via Milanese 300, 20099 Sesto S. Giovanni, Milan, Italy
| | - Alessandro Filippi
- Italian Society of General Medicine (SIMG), Via del Pignoncino 9-11, 50142, Florence, Italy
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Izadpanah R, Schächtele DJ, Pfnür AB, Lin D, Slakey DP, Kadowitz PJ, Alt EU. The impact of statins on biological characteristics of stem cells provides a novel explanation for their pleiotropic beneficial and adverse clinical effects. Am J Physiol Cell Physiol 2015. [DOI: 10.1152/ajpcell.00406.2014] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Statins reduce atherosclerotic events and cardiovascular mortality. Their side effects include memory loss, myopathy, cataract formation, and increased risk of diabetes. As cardiovascular mortality relates to plaque instability, which depends on the integrity of the fibrous cap, we hypothesize that the inhibition of the potential of mesenchymal stem cells (MSCs) to differentiate into macrophages would help to explain the long known, but less understood “non-lipid-associated” or pleiotropic benefit of statins on cardiovascular mortality. In the present investigation, MSCs were treated with atorvastatin or pravastatin at clinically relevant concentrations and their proliferation, differentiation potential, and gene expression profile were assessed. Both types of statins reduced the overall growth rate of MSCs. Especially, statins reduced the potential of MSCs to differentiate into macrophages while they exhibited no direct effect on macrophage function. These findings suggest that the limited capacity of MSCs to differentiate into macrophages could possibly result in decreased macrophage density within the arterial plaque, reduced inflammation, and subsequently enhance plaque stability. This would explain the non-lipid-associated reduction in cardiovascular events. On a negative side, statins impaired the osteogenic and chondrogenic differentiation potential of MSCs and increased cell senescence and apoptosis, as indicated by upregulation of p16, p53 and Caspase 3, 8, and 9. Statins also impaired the expression of DNA repair genes, including XRCC4, XRCC6, and Apex1. While the effect on macrophage differentiation explains the beneficial side of statins, their impact on other biologic properties of stem cells provides a novel explanation for their adverse clinical effects.
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Affiliation(s)
- Reza Izadpanah
- Applied Stem Cell Laboratory, Heart and Vascular Institute, Department of Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana
- Department of Surgery, Tulane University Health Sciences Center, New Orleans, Louisiana; and
| | - Deborah J. Schächtele
- Applied Stem Cell Laboratory, Heart and Vascular Institute, Department of Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Andreas B. Pfnür
- Applied Stem Cell Laboratory, Heart and Vascular Institute, Department of Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Dong Lin
- Applied Stem Cell Laboratory, Heart and Vascular Institute, Department of Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Douglas P. Slakey
- Department of Surgery, Tulane University Health Sciences Center, New Orleans, Louisiana; and
| | - Philip J. Kadowitz
- Department of Pharmacology, Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Eckhard U. Alt
- Applied Stem Cell Laboratory, Heart and Vascular Institute, Department of Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana
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van Vlerken LG, Arends P, Lieveld FI, Arends JE, Brouwer WP, Siersema PD, Janssen HL, van Erpecum KJ. Real life adherence of chronic hepatitis B patients to entecavir treatment. Dig Liver Dis 2015; 47:577-83. [PMID: 25936691 DOI: 10.1016/j.dld.2015.03.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 03/24/2015] [Accepted: 03/28/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Real-life prospective data on adherence to nucleos(t)ide analogues in chronic hepatitis B patients are scarce. AIMS We investigated adherence to entecavir in relation to virological response. METHODS In this prospective study, we provided 100 consecutive chronic hepatitis B patients with a medication dispenser that monitored entecavir intake during 16 weeks therapy. Hepatitis B virus (HBV) DNA was measured at baseline and after 16 weeks. Beliefs about medicines were evaluated using a questionnaire. RESULTS Adherence over 16 weeks averaged 85 ± 17%, with 70% of patients exhibiting good (i.e. ≥ 80%) adherence. Patients with poor (i.e. <80%) adherence were significantly younger (p=0.01), with more often indifferent attitudes towards entecavir (p=0.03) Viral breakthrough did not occur during the study. Adherence in patients with HBV DNA after 16 weeks > 20 IU/mL (n=18) and ≤ 20 IU/mL (n=81) averaged 83% and 91% respectively (p=0.19). In multivariate analysis, adherence was not a significant predictor of HBV DNA negativity (adjusted OR 1.02; p=0.34), after adjustment for duration of entecavir treatment (p<0.001) and HBe-status (p=0.001). CONCLUSIONS 70% of chronic hepatitis B patients exhibited good adherence to entecavir, with younger age and an indifferent attitude being risk factors for poor adherence. Poor adherence was not an independent predictor of virological response.
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Affiliation(s)
- Lotte G van Vlerken
- Department of Gastroenterology and Hepatology, University Medical Centrum Utrecht, Utrecht, The Netherlands
| | - Pauline Arends
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Faydra I Lieveld
- Department of Gastroenterology and Hepatology, University Medical Centrum Utrecht, Utrecht, The Netherlands; Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joop E Arends
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Willem Pieter Brouwer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Centrum Utrecht, Utrecht, The Netherlands
| | - Harry L Janssen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands; Liver Clinic, Toronto Western and General Hospital, University Health Network, Toronto, Canada
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Centrum Utrecht, Utrecht, The Netherlands.
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Svensson E, Nielsen RB, Hasvold P, Aarskog P, Thomsen RW. Statin prescription patterns, adherence, and attainment of cholesterol treatment goals in routine clinical care: a Danish population-based study. Clin Epidemiol 2015; 7:213-23. [PMID: 25759601 PMCID: PMC4345937 DOI: 10.2147/clep.s78145] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To examine the annual rate and cumulative prevalence of statin use in Denmark 2004–10, including adherence of use and attainment of cholesterol targets. Methods We included all individuals aged 18–86 years with a first statin prescription in Northern Denmark in 2004–10. We calculated the annual rate and cumulative prevalence of statin use. We examined cholesterol values before and after start of statins and the proportion reaching targets according to European guidelines and cardiovascular risk group. Results The study population consisted of 161,646 new statin users (51% men; median age 62 years). The peak rate of new statin initiators occurred in 2008, and a cumulative prevalence of 94 users per 1,000 population was reached in 2010. In total, 98% of new users started with simvastatin. Eighty-eight percent (142,897) did not switch statin type during follow-up. Overall persistence was 84%. The reduction in median total cholesterol in new statin users was 28% (from 6.3 mmol/L to 4.5 mmol/L), while it was 43% (from 4.0 mmol/L to 2.3 mmol/L) for low-density lipoprotein cholesterol. Among patients with very high cardiovascular risk, 66% attained the recommended total cholesterol target; corresponding figures were 74% among high-risk patients and 80% among low- to moderate-risk patients. Corresponding figures for low-density lipoprotein cholesterol were 54%, 82%, and 88%, respectively. Conclusions Statin use has become very prevalent in Danish adults, with high adherence. Cholesterol reduction after statin initiation is similar to that found in clinical trials, yet a substantial proportion of patients does not reach target cholesterol levels.
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Affiliation(s)
- Elisabeth Svensson
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Rikke Beck Nielsen
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Pål Hasvold
- AstraZeneca Nordic Baltic, Södertälje, Sweden
| | | | - Reimar W Thomsen
- Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Salazar-Gonzalez JA, Rosales-Mendoza S, Romero-Maldonado A, Monreal-Escalante E, Uresti-Rivera EE, Bañuelos-Hernández B. Production of a plant-derived immunogenic protein targeting ApoB100 and CETP: toward a plant-based atherosclerosis vaccine. Mol Biotechnol 2014; 56:1133-42. [PMID: 25143122 DOI: 10.1007/s12033-014-9793-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In an effort to initiate the development of a plant-based vaccination model against atherosclerosis, a cholera toxin B subunit (CTB)-based chimeric protein was designed to target both ApoB100 and CETP epitopes associated with immunotherapeutic effects in atherosclerosis. Epitopes were fused at the C-terminus of CTB to yield a protein called CTB:p210:CETPe. A synthetic gene coding for CTB:p210:CETPe was successfully transferred to tobacco plants with no phenotypic alterations. Plant-derived CTB:p210:CETPe was expressed and assembled in the pentameric form. This protein retained the target antigenic determinants, as revealed by GM1-ELISA and Western blot analyses. Higher expresser lines reached recombinant protein accumulation levels up to 10 µg/g fresh weight in leaf tissues and these lines carry a single insertion of the transgene as determined by qPCR. Moreover, when subcutaneously administered, the biomass from these CTB:p210:CETPe-producing plants was able to elicit humoral responses in mice against both ApoB100 and CETP epitopes and human serum proteins. These findings evidenced for the first time that atherosclerosis-related epitopes can be expressed in plants retaining immunogenicity, which opens a new path in the molecular farming field for the development of vaccines against atherosclerosis.
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Affiliation(s)
- Jorge Alberto Salazar-Gonzalez
- Laboratorio de Biofarmacéuticos Recombinantes, Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, Av. Dr. Manuel Nava 6, 78210, San Luis Potosí, SLP, Mexico
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Heuschmann PU, Kircher J, Nowe T, Dittrich R, Reiner Z, Cifkova R, Malojcic B, Mayer O, Bruthans J, Wloch-Kopec D, Prugger C, Heidrich J, Keil U. Control of main risk factors after ischaemic stroke across Europe: data from the stroke-specific module of the EUROASPIRE III survey. Eur J Prev Cardiol 2014; 22:1354-62. [DOI: 10.1177/2047487314546825] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 07/21/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry and Comprehensive Heart Failure Center, University of Würzburg, Germany
- Clinical Trial Center Würzburg, University Hospital Würzburg, Germany
| | - Julia Kircher
- Institute of Clinical Epidemiology and Biometry and Comprehensive Heart Failure Center, University of Würzburg, Germany
| | - Tim Nowe
- Department of Neurology, Vivantes Klinikum Neukölln, Germany
| | - Ralf Dittrich
- Department of Neurology, University of Münster, Germany
| | - Zeljko Reiner
- Department of Internal Medicine, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Croatia
| | - Renata Cifkova
- Department of Preventive Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Center for Cardiovascular Prevention, Charles University Medical School I and Thomayer Hospital, Prague, Czech Republic
| | - Branko Malojcic
- Department of Neurology, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Croatia
| | - Otto Mayer
- Department of Medicine II University Hospital Pilsen, Czech Republic
| | - Jan Bruthans
- Department of Preventive Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Center for Cardiovascular Prevention, Charles University Medical School I and Thomayer Hospital, Prague, Czech Republic
| | | | - Christof Prugger
- INSERM U970, Paris Cardiovascular Research Centre, University Paris Descartes, Paris, France
| | - Jan Heidrich
- Epidemiological Cancer Registry North Rhine-Westphalia, Münster, Germany
- Institute of Epidemiology and Social Medicine, University of Münster, Germany
| | - Ulrich Keil
- Institute of Epidemiology and Social Medicine, University of Münster, Germany
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Fàbregas M, Berges I, Fina F, Hermosilla E, Coma E, Méndez L, Medina M, Calero S, Serrano E, Morros R, Monteagudo M, Bolíbar B. Effectiveness of an intervention designed to optimize statins use: a primary prevention randomized clinical trial. BMC FAMILY PRACTICE 2014; 15:135. [PMID: 25027229 PMCID: PMC4112648 DOI: 10.1186/1471-2296-15-135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 07/08/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although hypercholesterolemia is considered a cardiovascular risk factor, in isolation it is not necessarily sufficient cause for a cardiovascular event. To improve event prediction, cardiovascular risk calculators have been developed; the REGICOR calculator has been validated for use in our population. The objective of this project is to develop an intervention with general practitioners (GPs) and evaluate its impact on prescription adequacy of cholesterol-lowering drugs in primary prevention of cardiovascular disease and in controlling the costs associated with this disease. METHODS This nonblinded, cluster-randomized clinical trial analyzes data from primary care electronic medical records (ECAP) and other databases. Inclusion criteria are patients aged 35 to 74 years with no known cardiovascular disease and a new prescription for cholesterol-lowering drugs during the 2-year study period. Dependent variables include the following: RETIRA, defined as new cholesterol-lowering drugs initiated during the year preceding the intervention, considered inadequate, and withdrawn during the study period; EVITA, defined as new cholesterol-lowering drugs initiated during the study period and considered inadequate; COST, defined as the total cost of inadequate new treatments prescribed; and REGISTER, defined as the recording of cardiovascular risk factors. Independent variables include the GP's quality-of-care indicators and randomly assigned study group (intervention vs control), patient demographics, and clinical variables. Aggregated descriptive analysis will be done at the GP level and multilevel analysis will be performed to estimate the intervention effect, adjusted for individual and GP variables. DISCUSSION The study objective is to generate evidence about the effectiveness of implementing feedback information programs directed to GPs in the context of Primary Care. The goal is to improve the prescription adequacy of lipid-lowering therapies for primary prevention. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01997671. November 28, 2013.
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Affiliation(s)
- Mireia Fàbregas
- ABS La Marina, SAP Esquerra, Institut Català de la Salut, Barcelona, Spain
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | | | - Francesc Fina
- Sistemes d’Informació d’Atenció Primària (SISAP) – Sistema d’Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP), Institut Català de la Salut, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Eduardo Hermosilla
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Ermengol Coma
- Sistemes d’Informació d’Atenció Primària (SISAP) – Sistema d’Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP), Institut Català de la Salut, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Leonardo Méndez
- Sistemes d’Informació d’Atenció Primària (SISAP) – Sistema d’Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP), Institut Català de la Salut, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Manuel Medina
- Sistemes d’Informació d’Atenció Primària (SISAP) – Sistema d’Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP), Institut Català de la Salut, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Sebastià Calero
- Àrea de Desenvolupament Clínic, Direcció Adjunta d’Afers Assistencials, Institut Català de la Salut, Institut Universitari d'investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Elena Serrano
- Centre d’Atenció Primària Baix a Mar, Consell comarcal del Garraf, Vilanova i la Geltrú, Barcelona, Spain
| | - Rosa Morros
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Mònica Monteagudo
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Bonaventura Bolíbar
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
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Ruokoniemi P, Sund R, Arffman M, Helin-Salmivaara A, Huupponen R, Keskimäki I, Vehko T, Korhonen MJ. Are statin trials in diabetes representative of real-world diabetes care: a population-based study on statin initiators in Finland. BMJ Open 2014; 4:e005402. [PMID: 24948750 PMCID: PMC4067810 DOI: 10.1136/bmjopen-2014-005402] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 05/28/2014] [Accepted: 05/30/2014] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To assess the representativeness of the Heart Protection Study (HPS) and the Collaborative Atorvastatin Diabetes Study (CARDS) for incident statin users. DESIGN A population-based analysis with linked register data. SETTING Finland. POPULATION 56 963 patients with diabetes initiating statin use from 2005 to 2008. MAIN OUTCOME MEASURES We determined the proportions of real-world patients who fulfilled the eligibility criteria for HPS and CARDS trials and assessed the cardiovascular disease (CVD) event rates, assumed to reflect the background CVD risk, for those eligible and ineligible. We used descriptive statistics to identify the patient characteristics, lipid-lowering interventions and adherence to statin therapy. RESULTS Of the real-world patients, 57% (N=32 582) fulfilled the eligibility criteria for HPS (DM) and 49% (N=20 499) of those without CVD for CARDS. The patients ineligible for HPS (DM) had a higher cumulative risk for CVD events than those eligible, whereas regarding CARDS the cumulative risks were of similar magnitude. The overall CVD event rates seemed to be comparable to those in the reviewed trials. Both trials were under-representative of women and users of antihypertensive agents and metformin. 27% and 29% of real-world patients had an initial statin dose corresponding to <20 mg of simvastatin. The proportions of patients who were deemed adherent were 57% in the real world and 85% in both trials. CONCLUSIONS Only half of the real-world patients would have qualified for the HPS (DM) and CARDS, limiting their representativeness for clinical practice. Women and users of antihypertensive agents and metformin were under-represented in both trials. These deviations reflect the changes in diabetes treatment over the years and are not expected to modify the average treatment effects of statins on CVD. Prescribing of lower statin doses in clinical practice than used in the trials and lower adherence may, however, attenuate the benefits in the real world.
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Affiliation(s)
- Päivi Ruokoniemi
- Department of Pharmacology, Drug Development and Therapeutics, FI-20014 University of Turku, Turku, Finland
| | - Reijo Sund
- Service Systems Research Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Martti Arffman
- Service Systems Research Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Arja Helin-Salmivaara
- Department of Pharmacology, Drug Development and Therapeutics, FI-20014 University of Turku, Turku, Finland
| | - Risto Huupponen
- Department of Pharmacology, Drug Development and Therapeutics, FI-20014 University of Turku, Turku, Finland
- Unit of Clinical Pharmacology, Turku University Hospital, Turku, Finland
| | - Ilmo Keskimäki
- Social and Health Services, National Institute for Health and Welfare, Helsinki, Finland
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Tuulikki Vehko
- Service Systems Research Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Maarit Jaana Korhonen
- Department of Pharmacology, Drug Development and Therapeutics, FI-20014 University of Turku, Turku, Finland
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50
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Family history of cardiovascular disease and influence on statin therapy persistence. Eur J Clin Pharmacol 2014; 70:701-7. [PMID: 24604354 DOI: 10.1007/s00228-014-1659-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 02/14/2014] [Indexed: 12/21/2022]
Abstract
PURPOSE Persistence to statins is low, presumably due to lack of perception of risk. Having a close relative suffering from cardiovascular disease (CVD) might increase persistence to statins. We investigated whether family history of CVD influences the discontinuation of statin treatment. METHODS A population-based cohort study was performed. Swedish registers on dispensed drugs, hospitalization and cause of death were linked to the Multi-generation Register. Incident statin users 20-72 years of age were identified between 2006 and 2007 and followed until 30 June 2009. Family history of CVD was defined as the presence of relatives with a previous cardiovascular event. Cox regression was used to study discontinuation and estimate the effect of the family history of CVD, adjusting for gender, age, education, income, healthcare provider, prevention's type, birth's country and residence's county. Stratified analysis by type and severity of cardiovascular event was performed. RESULTS A total of 86,002 patients were enrolled; 61.5 % had a family history of CVD. Discontinuation of statin therapy was not associated with family history of CVD (HR: 0.98; 95 % CI:0.96-1.01), except for patients with a family history of death from myocardial infarction (MI) (HR: 0.95 95 % CI:0.92-0.98). Young age, foreign background, low income, and statin for primary prevention and for secondary prevention when prescribed by a general practitioner were associated with higher risk of statin discontinuation. CONCLUSIONS Having relatives suffering from CVD did not consistently influence the persistence to statin treatment. A family history of death from MI had a slight significant positive effect on statin persistence, though not clinically relevant.
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