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Warden BA, Guyton JR, Kovacs AC, Durham JA, Jones LK, Dixon DL, Jacobson TA, Duell PB. Assessment and management of statin-associated muscle symptoms (SAMS): A clinical perspective from the National Lipid Association. J Clin Lipidol 2023; 17:19-39. [PMID: 36115813 DOI: 10.1016/j.jacl.2022.09.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Statin-associated muscle symptoms (SAMS) are the most common form of statin intolerance and are associated with increased risk of cardiovascular events that manifest from statin underutilization and discontinuation. The reported frequencies of SAMS are divergent in the literature. The writing group estimates the prevalence of SAMS, namely all muscle symptoms temporally related to statin use but without regard to causality, to be about 10% (range 5% to 25%), and the prevalence of pharmacological SAMS, specifically muscle symptoms resulting from pharmacological properties of the statin, to be about 1-2% (range 0.5% to 4%). In clinical practice, SAMS are likely to result from a combination of pharmacological and nonpharmacological effects, however this does not make the symptoms any less clinically relevant. Regardless of the etiology, SAMS need to be addressed in accordance with patients' preferences and experiences. This clinical perspective reviews the epidemiology and underlying pathophysiology of SAMS, and the cardiovascular consequences resulting from statin discontinuation. We present patient-centered clinical and communication strategies to mitigate SAMS and improve medication adherence and outcomes among statin users. Treatment strategies include 1) optimizing lifestyle interventions, 2) modulating risk factors that may contribute to muscle symptoms, 3) optimizing statin tolerability by dose reduction, decreased dosing frequency, or use of an alternate statin with more favorable pharmacokinetic properties, and 4) use of non-statins, emphasizing those with evidence for atherosclerotic risk reduction, either in combination with or in place of statin therapy depending on the patient's circumstances. The focus of this clinical perspective is sustainable lipoprotein goal achievement, which is important for cardiovascular risk reduction.
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Affiliation(s)
- Bruce A Warden
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA (Dr Warden), (Dr. Duell).
| | - John R Guyton
- Duke University Medical Center, Durham, NC, USA (Dr Guyton).
| | - Adrienne C Kovacs
- CPsych, Equilibria Psychological Health, Toronto, ON, Canada (Dr Kovacs).
| | | | - Laney K Jones
- Genomic Medicine Institute, Geisinger; Danville, PA, USA (Dr Jones).
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, United States (Dr Dixon).
| | - Terry A Jacobson
- Department of Medicine, Lipid Clinic and CVD Risk Reduction Program, Emory University School of Medicine, Atlanta, GA, United States (Dr Jacobson).
| | - P Barton Duell
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA (Dr Warden), (Dr. Duell); Division of Endocrinology, Diabetes, and Clinical Nutrition, Oregon Health & Science University, Portland, OR.
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Blokhina AV, Ershova AI, Meshkov AN, Limonova AS, Mikhailina VI, Drapkina OM. Lipid Clinic is an Efficacious Model of Preventive Medicine. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-01-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Aim. To characterize patients accessing lipid clinic and assess the efficiency of treatment in a specialized medical center.Material and methods. A retrospective analysis of the surviving medical records of outpatients who visited the lipid clinic of the National Research Center for Therapy and Preventive Medicine (Moscow, Russia) in 2011-2019 (n=675) was carried out. Cardiovascular risk (CVR) and target lipoproteins levels were evaluated in accordance with actual guidelines for the diagnostics and correction of dyslipidemias.Results. The mediana of lipid clinic patients age was 57 [46;65] years. Female persons attend lipid clinic more often (61.5%). 48.5% of patients had low density lipoprotein cholesterol (LDL-c) >4.9 mmol/L, 7.7% had triglycerides level >5.5 mmol/L. Most of the patients were diagnosed with type IIa hyperlipidemia (44,1%) or type IIb (28,0%). Inherited impaired lipid metabolism was diagnosed in 27.7% individuals. 12.7% of the patients had familial hypercholesterolemia, 57.4% – had secondary causes of impaired lipid metabolism. More than half of the patients (52.4%) had low or moderate CVR, 28.1% had a very high CVR. High or very high CVR individuals revisited the lipid clinic more often than people with lower risk (68.2% vs. 35.4%). Revisiting patients (25.4%) reached LDL-c targets more often (33.3% of very high CVR patients; 45.5% of moderate-risk people) than in ordinary outpatient practice. High-intensity statin therapy was recommended for 32% of patients, and combined lipid-lowering therapy – for 14.8%. Among very high CVR individuals, combined lipid-lowering therapy was prescribed for 38.5%. Given the lipid-lowering therapy prescribed in the lipid clinic, LDL-с<1.8 mmol/L and<1.5 mmol/L will be achieved at 40.7% and 32.9% of patients with very high СVR.Conclusion. Lipid clinic is an important part of the medical care system for long-term follow-up of patients with impaired lipid metabolism, and it is more efficient in achieving target values of lipids and correcting risk factors in comparison with the primary medical service.
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Affiliation(s)
- A. V. Blokhina
- National Medical Research Center for Therapy and Preventive Medicine
| | - A. I. Ershova
- National Medical Research Center for Therapy and Preventive Medicine
| | - A. N. Meshkov
- National Medical Research Center for Therapy and Preventive Medicine
| | - A. S. Limonova
- National Medical Research Center for Therapy and Preventive Medicine
| | - V. I. Mikhailina
- National Medical Research Center for Therapy and Preventive Medicine
| | - O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine
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Wierzbicki AS, Viljoen A, Viljoen S, Martin S, Crook MA, Reynolds TM. Review of referral criteria to lipid clinics and outcomes of treatment in four UK centres. Int J Clin Pract 2018; 72:e13242. [PMID: 32500653 DOI: 10.1111/ijcp.13242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 07/14/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Little data exist on the referral patterns and effectiveness of lipid clinics. METHODS An audit was conducted in four clinics of 100 consecutive referrals each. Data were recorded on referral criteria, cardiovascular disease (CVD) risk factors, drug history, investigations, diagnoses, therapies, results and referrals. RESULTS Patients were aged 56 ± 14 years, 47% were male and 87% were primary prevention. Risk factors included smoking (16%), type 2 diabetes (13%) and hypertension (13%). Referrals were made for hypercholesterolaemia (68%), diagnosis of FH (31%), statin intolerance (23%) and hypertriglyceridaemia (23%). Initial total cholesterol (TC) was 7.65 ± 2.64 mmol/L, triglycerides (TG) 2.17 (0.41-76.9 mmol/L) mmol/L, HDL-C 1.53 ± 0.71 mmol/L, LDL-C 4.57 ± 1.66 mmol/L with non-HDL-C 5.90 ± 2.09 mmol/L. Criteria for FH were met in 21% with genetic testing in 13% and lipid cascade testing in 30% of index cases. Triglycerides >20 mmol/L were present in 4%. The diagnosis was changed in 21%: hypercholesterolaemia (7%), mixed hyperlipidaemia (7%) and hypertriglyceridaemia (7%). Hepatic steatosis was identified in 14.5%. Lipoprotein(a) levels >125 nmol/L occurred in 41% in one clinic. Therapy changes included altered statins (40%), addition of a fibrate (11%) or ezetimibe (8%). These reduced TC by 1.92 mmol/L (19%; P = 0.0001), LDL-C 1.07 mmol/L (15%; P = 0.02), non-HDL-C 1.50 mmol/L (16%; P < 0.001), and TG 2.3 (-4 to 38) mmol/L (16%; P < 0.001) with 11% extra achieving TG <5 mmol/L while HDL-C increased by 7% (P = 0.37). CONCLUSIONS Lipid clinics have diverse functions including diagnosis of FH, managing severe hypercholesterolaemia, mixed hyperlipidaemia and statin intolerance. Effectiveness criteria of average reductions of 1.5 mmol/L in TC or non-HDL-C, 1 mmol/L in LDL-C and 2 mmol/L in TG would be reasonable for newly referred patients.
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Affiliation(s)
- Anthony S Wierzbicki
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Adie Viljoen
- Department of Metabolic Medicine/Chemical Pathology, North East Hertfordshire NHS Trust, Lister Hospital, Stevenage, Hertfordshire, UK
| | - Sumarie Viljoen
- Department of Metabolic Medicine/Chemical Pathology, North East Hertfordshire NHS Trust, Lister Hospital, Stevenage, Hertfordshire, UK
| | - Steven Martin
- Department of Clinical Biochemistry and Immunology, Northwest Anglia NHS Foundation Trust, Peterborough, Cambridgeshire, UK
| | - Martin A Crook
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Timothy M Reynolds
- Department of Metabolic Medicine/Chemical Pathology, Queen's Hospital, Burton-on-Trent, UK
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Kohli M, Patel K, MacMahon Z, Ramachandran R, Crook MA, Reynolds TM, Wierzbicki AS. Pro-protein subtilisin kexin-9 (PCSK9) inhibition in practice: lipid clinic experience in 2 contrasting UK centres. Int J Clin Pract 2017; 71. [PMID: 28994502 DOI: 10.1111/ijcp.13032] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 09/13/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Prescribing criteria have been suggested for proprotein convertase subtilisin kexin-9 (PCSK-9) inhibitors but few studies exist of their real-world effectiveness. METHODS This study audited PCSK-9 inhibitor therapy in 105 consecutive patients from two hospital centres-a university hospital (UH; n = 70) and a district general hospital (DGH; n = 35). Baseline characteristics including cardiovascular disease risk factors, NICE qualification criteria, efficacy and side effects were assessed. RESULTS Baseline LDL-C levels were similar in both centres. NICE criteria were met for 2.05 items in the whole study (UH patients 1.7 and DGH patients 2.7). District general hospital patients were more likely to have familial hypercholesterolaemia (89 vs 69%; P = .02); intolerance to statins (94 vs 52%; P < .001) and polyvascular disease (42% vs 17%; P = .005). Prescriptions (evolocumab 73%; alirocumab 23%) were collected by 76% of patients (UH 64% vs DGH 100%). Therapy was discontinued by time of review in 15% of patients (UH 7% vs DGH 25%; P = .02). In adherent patients PCSK-9 inhibitor treatment reduced TC by 28% (2.24 ± 2.39 mmol/L; P < .001) and LDL-C by 49% (2.10 ± 1.33 mmol/L; P < .001). A LDL-C < 2.5 mmol/L was achieved in 30% of patients and <2.0 mmol/L in 20%. PCSK-9 therapy was effective and safe in patients with increased lipoprotein (a), diagnosed muscle diseases (including myopathies and muscular dystrophy) or poststatin rhabdomyolysis, nephrotic syndrome or HIV disease. Mixed results were obtained in patients with significant mixed hyperlipidaemia. CONCLUSIONS This study suggests that PCSK-9 inhibitors are effective but that prescriptions should not be changed to long-term delivery until patients have been reviewed and shown to be adherent.
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Affiliation(s)
- Monika Kohli
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Kinjal Patel
- Department of Metabolic Medicine/Chemical Pathology, Queen's Hospital, Burton-on-Trent, UK
| | - Zofia MacMahon
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Radha Ramachandran
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Martin A Crook
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
| | - Timothy M Reynolds
- Department of Metabolic Medicine/Chemical Pathology, Queen's Hospital, Burton-on-Trent, UK
| | - Anthony S Wierzbicki
- Department of Metabolic Medicine/Chemical Pathology, Guy's & St Thomas' Hospitals, London, UK
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Younossi ZM, Otgonsuren M, Henry L, Arsalla Z, Stepnaova M, Mishra A, Venkatesan C, Hunt S. Inpatient resource utilization, disease severity, mortality and insurance coverage for patients hospitalized for hepatitis C virus in the United States. J Viral Hepat 2015; 22:137-45. [PMID: 24813350 DOI: 10.1111/jvh.12262] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 03/17/2014] [Indexed: 12/15/2022]
Abstract
Although the incidence of new hepatitis C virus (HCV) infection has fallen, HCV-related complications are on the rise. Our aim was to assess and describe the 2005-2009 national inpatient mortality and resource utilization trends for patients with HCV. Data from the National Inpatient Sample (NIS) and the National Hospital Discharge Survey (NHDS) between 2005 and 2009 were analyzed. Included were all adult hospital discharges with HCV-related ICD-9 codes. Incremental hospital charge, in-hospital mortality and length of stay (LOS) were estimated using n = 1000 bootstrap replicates clustered by unique hospital identifier. A total of 123 939 (0.38%) discharges were related to HCV (primary or secondary diagnosis). In-hospital mortality increased from 1.7% (2005) to 2.6% (2009) (P < 0.001). Inflation-adjusted charges increased 2% annually from 2005 ($16 455 ± $570) to 2009 ($17 532 ± $1007, P = 0.029). This increase occurred despite the average LOS (5 days) and hospital costs ($6500) remaining stable while at the same time, hospital-to-hospital transfer admissions and disposition to home health care increased. HCV-related hepatocellular carcinoma predicted longer hospital stay and death; older age predicted death; and receiving more procedures predicted higher hospital costs. The percentage of patients with private insurance significantly decreased (4.7%), while government-sponsored insurance and uninsured increased by 2.5% and 2.1%, respectively (P < 0.05). Uninsured patients had a 49%-72% greater chance of dying during hospitalization than those with government-sponsored insurance. HCV-related inpatient mortality and resource utilization have increased. HCC was the largest predictor for mortality and resource utilization. These data are consistent with the rising clinical and societal burden of chronic hepatitis C in the United States.
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Affiliation(s)
- Z M Younossi
- Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA; Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
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Viljoen A, Wierzbicki AS. Safety and efficacy of laropiprant and extended-release niacin combination in the management of mixed dyslipidemias and primary hypercholesterolemia. DRUG HEALTHCARE AND PATIENT SAFETY 2010; 2:61-71. [PMID: 21701618 PMCID: PMC3108693 DOI: 10.2147/dhps.s7302] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Indexed: 01/26/2023]
Abstract
Statins form the cornerstone of pharmaceutical cardiovascular disease prevention. However, despite very effective statin intervention, the majority of events remain unpreventable. In some cases statin therapy alone is insufficient to achieve adequate lipid levels whereas other patients are unable to tolerate statins. This calls for additional treatment options. Niacin has a long history of success in reducing low-density lipoprotein cholesterol and triglycerides, and increasing high-density lipoprotein cholesterol. It was the first lipid-lowering drug to demonstrate a reduction in cardiovascular events, and remains the only one that has consistently shown benefits on surrogate outcomes when added to background therapies of other lipid-lowering drugs, including statins. Niacin’s uptake in clinical practice has been less successful due to its side-effect profile, most notable being flushing. The uncovering of the mechanism by which flushing is induced, together with the development of a prostaglandin D2 receptor inhibitor (laropiprant) which reduces this downstream flushing effect of niacin, has sparked new promise in therapeutic lipid management. It provides an additional treatment option into managing lipid abnormalities. The uptake in clinical practice of the niacin–laropiprant combination will depend on the relative improvements experienced by the patient in the side-effect profile compared to other treatment options, as well as on the the keenly-awaited outcome studies currently underway. Until these data become available guidelines and recommendations are unlikely to change and niacin’s position in therapeutic cardiovascular risk prevention will be determined by clinician opinion and experience, and patient preferences.
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