Quality of lipid-lowering therapy in patients with ischaemic heart disease: a register-based study in 3477 patients

Implications of a defined daily dose fixed database for drug utilization research studies: The case of statins in Portugal

AIMS

Given the discrepancies between PDDs (prescribed daily doses) and DDDs (defined daily doses), we aimed to assess the extent of error in the results of an 18-year population-level study on statin utilization in Portugal.

METHODS

The Portuguese regulatory agency provided data for the period 2000-2018 on statin dispensing (C10AA). The DDDs were gathered from the ATC/DDD database. DDDs were calculated by the DDD year-by-year approach (DDD_YEAR ) and by the DDD last-year approach (DDD_LAST ). PDDs were calculated according to the year-by-year approach (PDD_YEAR ). Statin annual utilization rates per 1000 inhabitants per day were also calculated. Percent errors were calculated for PDD_YEAR and DDD_YEAR units.

RESULTS

The DDD_YEAR approach revealed decreases in the consumption of atorvastatin, fluvastatin, lovastatin, pravastatin and simvastatin in 2009, when their DDD was modified. Conversely, the results from both DDD_LAST and PDD_YEAR approaches indicated gradual changes in the actual consumption of all statins in Portugal. Before 2009, atorvastatin, pravastatin and simvastatin utilization was greatly overestimated by DDD_YEAR /1000 inhabitants/day. The average dose of lovastatin prescribed in the past 18 years (20 mg) was below the assigned DDDs during the study period, varying from 30 mg to 45 mg. Conversely, the PDD for fluvastatin was above the DDD values (ranging from 40 mg in 2000 to 70 mg in 2016). For atorvastatin, pravastatin and simvastatin, national PDDs were above the assigned DDD until the DDD modification in 2009.

CONCLUSIONS

A more dynamic system, based on national and annually updated DDDs, should be able to reduce discrepancies between DDDs and PDDs and the bias in utilization studies.

Prevalence and characteristics of patients with low levels of low-density lipoprotein cholesterol in northern Denmark: a descriptive study

BACKGROUND

With the emergence of new lipid-lowering therapies, more patients are expected to achieve substantial lowering of low-density lipoprotein cholesterol (LDL-C). However, there are limited data examining the clinical experience of patients with low (<1.3 mmol/L) or very low (<0.65 mmol/L) levels of LDL-C. To provide information on patients with low LDL-C, we identified and characterized persons with low LDL-C using data from Danish medical databases.

METHODS

Using a population-based clinical laboratory database, we identified adults with at least one LDL-C measurement in northern Denmark between 1998 and 2011 (population approximately 1.5 million persons). Based on the lowest measurement during the study period, we divided patients into groups with low (<1.3 mmol/L), moderate (1.3-3.3 mmol/L), or high (>3.3 mmol/L) LDL-C. We described their demographic characteristics, entire comorbidity history, and 90-day prescription history prior to the lowest LDL-C value measured. Finally, we further restricted the analysis to individuals with very low LDL-C (<0.65 mmol/L).

RESULTS

Among 765,503 persons with an LDL-C measurement, 23% had high LDL-C, 73% had moderate LDL-C, and 4.8% had low LDL-C. In the latter group, 9.6% (0.46% of total) had very low LDL-C. Compared with the moderate and high LDL-C categories, the low LDL-C group included more males and older persons with a higher prevalence of cardiovascular disease, diabetes, chronic pulmonary disease, ulcer disease, and obesity, as measured by hospital diagnoses or relevant prescription drugs for these diseases. Cancer and use of psychotropic drugs were also more prevalent. These patterns of distribution became even more pronounced when restricting to individuals with very low LDL-C.

CONCLUSION

Using Danish medical databases, we identified a cohort of patients with low LDL-C and found that cohort members differed from patients with higher LDL-C levels. These differences may be explained by various factors, including prescribing patterns of lipid-lowering therapies.

Statin use and survival following glioblastoma multiforme

AIM

While some studies indicate a potential chemopreventive effect of statin use on the risk of glioma, the effect of statins on the prognosis of brain tumours has not yet been examined. We thus conducted a cohort study evaluating the influence of statin use on survival in patients with glioblastoma multiforme (GBM).

METHODS

We identified 1562 patients diagnosed with GBM during 2000-2009 from the Danish Cancer Registry and linked this cohort to Danish nationwide demographic and health registries. Within the GBM cohort, each patient recorded as using statins prior to diagnosis (defined as ≥ 2 redeemed prescriptions) was matched to two statin non-users (<2 redeemed prescriptions) by propensity scores based on age, gender, year of diagnosis, comorbidity, and use of selected drugs. Cox proportional hazard models were used to compute hazard ratios (HRs) and 95% confidence intervals (CI) for all-cause death associated with prediagnostic statin use.

RESULTS

A total of 339 GBM patients were included in the analyses. Of these, 325 died during median follow-up of 6.9 months (interquartile range: 3.8-13.4 months). Prediagnostic statin use was associated with a reduced HR of death (0.79; 95% CI: 0.63-1.00). The HRs decreased with increasing duration or intensity of prediagnostic statin use [long-term (≥ 5 years) statin use: HR 0.75 (95% CI: 0.47-1.20); high-intensity statin use: HR 0.66 (95% CI: 0.44-0.98)]. Additional adjustment for oncotherapeutic modalities yielded similar results (overall HR 0.80, 95% CI: 0.63-1.01).

CONCLUSION

Long-term prediagnostic statin use may improve survival following GBM.

Statin medication in patients treated with antiepileptic drugs in Norway

PURPOSE

The lipid-lowering response of statins metabolized by cytochrome P450 3A4 (CYP3A4) has previously been shown to be diminished by concurrent use of enzyme-inducing antiepileptic drugs (EIAEDs). The aim of this study was to compare statin prescription in patients receiving EIAEDs versus non-enzyme-inducing antiepileptic drugs (NEIAEDs), before and after introduction of prescribing restrictions for statins in Norway.

METHODS

The Norwegian Prescription Database was used to extract data on patients using antiepileptic drugs and statins during 2004 and 2008. Statin type and dose used were compared between patients treated with at least one EIAED (i.e., carbamazepine, phenobarbital, phenytoin, primidone) and those receiving NEIAEDs only (i.e., all other antiepileptic drugs).

RESULTS

The number of included patients co-medicated with statins and AEDs was 4855 in 2004 and 9880 in 2008. Among these patients, 2827 and 3160, respectively, were treated with EIAEDs. The CYP3A4 statins (i.e., simvastatin, atorvastatin and lovastatin) accounted for 85% of all statins in 2004, increasing to 93% in 2008. There was no significant difference in the likelihood of being prescribed a CYP3A4 statin versus a non-CYP3A4 statin among patients receiving EIAEDs and NEIAEDs. The average daily dose of individual CYP3A4 statins was not different between the AED groups.

CONCLUSIONS

The present study shows that the interaction risk between CYP3A4-metabolized statins and EIAEDs is largely overlooked in Norwegian clinical practice. To avoid therapeutic failure of statin treatment in patients using AEDs, implementation of strategies for systematic management of drug interactions is warranted.

Adherence of hospital-based cardiologists to lipid guidelines in patients at high risk for cardiovascular events (2L registry)

OBJECTIVES

According to various national and international guidelines, the target LDL-C level is <100 mg/dl for patients with established coronary heart disease (CHD) or CHD risk equivalent (CE). We aimed to investigate aspects of the lipid-lowering management of patients at high cardiovascular risk in-hospital care and the achievement of target values.

METHODS

In the internet-based 2L registry in Germany (2005-2006), cardiologists in 42 hospitals documented at a single visit 3,131 consecutive patients with known CHD, and/or diabetes mellitus, peripheral arterial disease, or a 10-year CHD risk >20% (summarized as CE), who were on chronic statin treatment. They received instructions on the guidelines and instant feedback on the effect of their treatment decisions (educational study component).

RESULTS

The three groups comprised 1,458 patients with CHD + CE (46.6%; median LDL-C 107 mg/dl), 1,104 patients with CHD only (35.3%; median LDL-C 104 mg/dl), and 569 with CE only (18.2%; median LDL-C 111 mg/dl). At admission, LDL-C levels <100 mg/dl were observed in 43.1, 44.8 and 37.9% of patients in the three groups, respectively. Statin doses at admission were usually in the low to intermediate range (e.g., simvastatin 10-20 mg/day). Cardiologists switched to another statin in 14.6%, increased the dose of statins (if same drug) in 22.9% (mean increase from 26.8 mg/day at baseline to 31.6 mg/day) and/or added a cholesterol absorption inhibitor (CAI) in 11.6%. The cardiologists' intervention improved estimated LDL-C levels (using a lipid calculator); however, the 100 mg/dl LDL-C target was only reached in 49.0, 48.5, and 42.9%.

CONCLUSIONS

When compared with earlier studies in the outpatient setting, the treatment to target for LDL-C of high-risk CHD patients has improved, but is not satisfactory.

Current cardiovascular risk management patterns with special focus on lipid lowering in daily practice in Switzerland

BACKGROUND

There may be a considerable gap between LDL cholesterol (LDL-C) and blood pressure (BP) goal values recommended by the guidelines and results achieved in daily practice.

DESIGN

Prospective cross-sectional survey of cardiovascular disease risk profiles and management with focus on lipid lowering and BP lowering in clinical practice.

METHODS

In phase 1, the cardiovascular risk of patients with known lipid profile visiting their general practitioner was anonymously assessed in accordance to the PROCAM-score. In phase 2, high-risk patients who did not achieve LDL-C goal less than 2.6 mmol/l in phase 1 could be further documented.

RESULTS

Six hundred thirty-five general practitioners collected the data of 23 892 patients with known lipid profile. Forty percent were high-risk patients (diabetes mellitus or coronary heart disease or PROCAM-score >20%), compared with 27% estimated by the physicians. Goal attainment rate was almost double for BP than for LDL-C in high-risk patients (62 vs. 37%). Both goals were attained by 25%. LDL-C values in phase 1 and 2 were available for 3097 high-risk patients not at LDL-C goal in phase 1; 32% of patients achieved LDL-C goal of less than 2.6 mmol/l after a mean of 17 weeks. The most successful strategies for LDL-C reduction were implemented in only 22% of the high-risk patients.

CONCLUSION

Although patients at high cardiovascular risk were treated more intensively than low or medium risk patients, the majority remained insufficiently controlled, which is an incentive for intensified medical education. Adequate implementation of Swiss and International guidelines would expectedly contribute to improved achievement of LDL-C and BP goal values in daily practice.

Lipid lowering treatment patterns and goal attainment in Nordic patients with hyperlipidemia

OBJECTIVES

Observational studies and surveys have shown that lipid-lowering treatment is not optimal neither with regard to number of patients treated nor with number of patients achieving recommended goals. To address this issue in the Nordic countries, we evaluated the published literature on lipid-lowering therapies in preventive cardiology in this region.

DESIGN

Nordic papers published from 2000 throughout 2006 dealing with lipid-lowering management in coronary heart disease prevention were identified. In total, 19 studies were analyzed.

RESULTS

Approximately half of the patients are inadequately treated and have not achieved recommended treatment goals of total cholesterol <5.0 and LDL-cholesterol <3.0 mmol/L. Statins were prescribed most often in low or medium doses. The predictive factors for treatment were cholesterol level, risk of cardiovascular disease, previous cardiovascular disease, age, and gender.

CONCLUSIONS

There is a considerable need to improve standards of preventive cardiology. Statins have to be given evidence based to achieve treatment goals according to lipid levels, and higher doses of statins or combination therapy with a statin and a cholesterol absorption inhibitor or niacin is often needed.

Cardiac rehabilitation: health characteristics and socio-economic status among those who do not attend

BACKGROUND

Cardiac rehabilitation (CR) is well documented, in randomised trials, to reduce mortality risk after myocardial infarction (MI). Selection of healthy patients for CR is a relatively unexplored problem. Our aims were to identify predictors of CR-attendance and to describe the prognosis as concerns mortality, re-admission and invasive treatment among CR-attendees as compared to CR-non-attendees.

METHODS

From a cohort of 138 290 persons aged 30-69 years, we identified consecutive MI patients, between 1 April 2000 and 31 March 2002. There were 206 MI patients, who survived until admission, and among the 200 who survived 30 days, 145 (72.5%) attended a comprehensive CR programme. Data were obtained from patient charts and from Danish population registers, and as a result we had no non-participation for the study.

RESULTS

The 2-year mortality proportions for patients surviving the first 30 days of admission were 2.8 and 21.8% among CR-attendees and CR-non-attendees, respectively (P < 0.0001). Among CR-non-attendees, there was a smaller fraction having an invasive treatment performed as compared with CR-attendees. By multiple logistic regression controlling for age and sex, CR-attendance was associated with chest pain, whereas CR-non-attendance was associated with low gross income, single living and inverted T-wave in the electrocardiogram.

CONCLUSION

CR attendance rate was 72.5%. Non-attendees have a higher mortality risk, which in part may be attributed to selection of healthy patients. Non-attendees are older and more likely to have atypical symptoms at admission, a low socioeconomic status and to live alone. Special attention is needed to improve CR attendance among such patients.

Aspects of statin prescribing in Norwegian counties with high, average and low statin consumption - an individual-level prescription database study

Background

A previous study has shown that variations in threshold and intensity (lipid goal attainment) of statins for primary prevention contribute to regional differences in overall consumption of statins in Norway. Our objective was to explore how differences in prevalences of use, dosing characteristics, choice of statin and continuity of therapy in individual patients adds new information to previous results.

Methods

Data were retrieved from The Norwegian Prescription Database. We included individuals from counties with high, average, and low statin consumption, who had at least one statin prescription dispensed during 2004 (N = 40 143).

1-year prevalence, prescribed daily dose (PDD), statin of choice, and continuity of therapy assessed by mean number of tablets per day.

Results

The high-consumption county had higher prevalence of statin use in all age groups.

Atorvastatin and simvastatin were dispensed in 79–87% of all statin users, and the proportion was significantly higher in the high-consumption county.

The estimated PDDs were higher than the DDDs, up to twice the DDD for atorvastatin. The high-consumption county had the highest PDD for simvastatin (25.9 mg) and atorvastatin (21.9 mg), and more users received tablets in the upper range of available strengths. Continuity of therapy was similar in the three counties.

Conclusion

Although differences in age-distribution seems to be an important source of variation in statin consumption, it cannot account for the total variation between counties in Norway. Variations in prevalences of use, and treatment intensity in terms of PDD and choice of statin also affect the total consumption. The results in this study seems to correspond to previous findings of more frequent statin use in primary prevention, and more statin users achieving lipid goal in the highest consuming county.

Long-term achievement of the therapeutic objectives of lipid-lowering agents in primary prevention patients and cardiovascular outcomes: An observational study

AIMS

Lowering elevated cholesterol levels reduces cardiovascular (CV) morbidity and mortality. Nonetheless, most patients treated with lipid-lowering agents (LLA) do not reach recommended therapeutic objectives. In a setting of primary care in France, we investigated the association between LDL-cholesterol goal attainment and the occurrence of CV events in primary prevention patients with multiple CV risk factors (> or = 3). According to national guidelines, the therapeutic objective (TO) for such patients is an LDL-cholesterol value below 130 mg/dL.

METHODS

579 patients treated with LLA and with LDL-cholesterol values documented at least once a year over a period of at least 3 years (2000-2002) were allocated to three groups based on the number of years the TO was attained during the follow-up period: in all 3 years (TO+++: n=145), only part of the time (TO intermediate: n=256), and never (TO---: n=178). CV events (angina pectoris, myocardial infarction, heart failure, stroke, peripheral artery disease) occurring during the last year of observation (2002) were retrospectively collected. The occurrence risk (OR) of CV events was assessed based on TO status, with a logistic regression model to adjust for baseline differences in CV risk factors.

RESULTS

Only a quarter of patients attained TO during all 3 study years. CV events during the third year of observation occurred in 5.5%, 10.5% and 12.9% of patients in the TO+++, TO intermediate and TO--- groups, respectively. Compared with TO+++ patients, the risk of CV events increased significantly in TO intermediate (OR=2.34, 95% CI=[1.01-5.39]) and TO--- patients (OR=2.99, 95% CI=[1.26-7.08]).

CONCLUSION

In real practice, a prolonged attainment of TO is rarely observed in high CV risk patients treated with LLA as primary prevention. Therapeutic failure is related to an increased incidence of cardiovascular morbidity. Our data strongly support the need to improve adherence to treatment guidelines to achieve effective cardiovascular prevention.

Statin use after acute myocardial infarction: a nationwide study in Denmark

AIMS

To study outpatient statin use after first acute myocardial infarction (AMI) in Denmark between 1995 and 2002 and to determine the predictors of statin use.

METHODS

This is a nationwide population-based study using administrative registries. Patients with first AMI between 1995 and 2002 older than 30 years of age and alive 6 months after discharge (n = 45 219) were identified through the National Patient Registry. The statins purchased by these patients within 6 months after discharge were determined using the Registry of Medicinal Product Statistics, a nationwide prescription database.

RESULTS

Statin use following AMI increased from 13% in 1995 to 61% in 2002. In 2002, 81% of patients aged 30-64 years used statins. Older patients used fewer statins, but use increased more among patients aged 75-84 years: from 1.3% to 43%. Use in elderly patients did not differ according to gender in 2000-02, but young men used more than younger women. In 2000-02, patients with diabetes (odds ratio (OR): 0.84; 95% confidence interval (CI): 0.74-0.95) and with heart failure (OR: 0.70; 95% CI: 0.64-0.76) were undertreated; this trend was present throughout the period.

CONCLUSIONS

In this nationwide study, younger patients after AMI had high statin use in 2002, but high-risk patients such as those with diabetes and heart failure were still being undertreated.