Conversion to atorvastatin in patients intolerant or refractory to simvastatin therapy: the CAPISH study

Strategies to preserve the use of statins in patients with previous muscular adverse effects

PURPOSE

The published evidence on strategies for avoiding the discontinuation of statin therapy due to muscular adverse effects is reviewed.

SUMMARY

Statin medications are a cornerstone of the prevention and treatment of coronary heart disease, but about 20% of treated patients develop myalgia or other muscle-related adverse effects that can lead to the discontinuation of statin use. As there are no consensus guidelines or firm practice recommendations on continuing or reinitiating statin therapy in patients who experience statin-related muscular adverse effects, a literature search was conducted to evaluate a variety of strategies that have been studied. The search results indicated that the most widely used strategies are (1) alternative statin dosing, (2) co-enzyme Q10 supplementation, (3) vitamin D supplementation, (4) conversion to red yeast rice (RYR) therapy, and (5) conversion to a different statin. While positive results in some patients have been reported with all of the strategies reviewed, the available evidence is insufficient to support the routine use of any of the strategies in clinical practice. In particular, the use of RYR, which contains a naturally occurring statin, is not recommended due to limited and inconsistent study results and uncertainty about the contents of commercially available RYR products.

CONCLUSION

In patients intolerant to statin therapy due to myalgia or other muscular adverse effects, strategies such as alternative statin dosing schedules, coenzyme Q10 or vitamin D supplementation, and conversion to RYR or an alternative statin may allow some patients to continue to receive the benefits of lipid-lowering therapy.

Generic and therapeutic statin switches and disruptions in therapy

BACKGROUND

The study objective was to compare dose-equivalence, adherence and subsequent switch rates among patients recently switched from a branded to generic version of the same statin (generic substitution, GS) vs. those switched from branded statin to generic version of a different statin (therapeutic substitution, TS).

METHODS

In a retrospective cohort analysis among adult enrollees in over 90 US health plans, the authors identified adult patients who switched from a branded to generic statin from July-December 2006 (simvastatin became generic in June 2006). Patients were classified by type of statin switch: GS (e.g., branded simvastatin --> generic simvastatin), and TS (e.g., branded atorvastatin --> generic simvastatin). Demographic and clinical data were collected from claims before switch through 6 months follow-up. Separate outcomes of interest included proportion of patients that switched to a less potent daily dose, that switched back to previous branded statin after switch, and that were at least 80% adherent during the 6 months after initial switch. Significant predictors of each clinical outcome were identified using multivariable logistic regression models, adjusting for differences between groups in covariates and potential confounders.

RESULTS

The 6-month TS (n = 3807) and GS (n = 40,165) groups were generally similar demographically. Compared to GS, TS patients were significantly more likely to be switched to a less potent dose (26.2% vs. 0.5%, adjusted odds ratio [AOR] in patients with high-potency index medication = 83.4, p < 0.0001); 33% less likely to be adherent in the 6 months after switch (67.7% vs. 75.9%, AOR in patients with no switch in first 6 months follow-up = 0.67, p < 0.0001); and four times more likely to switch back to previous branded statin (11.3% vs. 2.9%, AOR = 4.1, p < 0.0001).

LIMITATIONS

This study did not account for co-payment changes, lipid measurements, or changes in pill burden.

CONCLUSIONS

While this study did not have data on why patients had TS (e.g., for cost or clinical reasons), TS was more likely to involve a subsequent disruption to statin therapy than GS. TS could potentially lead to adverse impacts on patients' outcomes, and should be studied further.

Achieving Vascular Risk Factor Targets: A Survey of a London General Practice

We assessed lipid goal achievement in patients at high risk for vascular events from a general practice (London, United Kingdom). Patients were identified as those with a prescription for hypolipidaemic medication, a significant (>20%) Framingham risk, and from the myocardial infarction register. Two hundred forty-five patients were currently taking a statin (average dose, 23.1 mg/day). Cholesterol, high-density lipoprotein—cholesterol, low-density lipoprotein—cholesterol, and triglycerides changed significantly following statin treatment. Of 285 patients who had taken statins at some time point, 11 (3.9%) were intolerant, 5 of which subsequently tolerated another statin. Approximately 10.1% of patients discontinued statin treatment for unclear reasons. Only 64 patients (29.1% of 220) reached the Joint British Societies' Guidelines on Prevention of Cardiovascular Disease target of a total cholesterol of <4.0 mmol/L; 50 patients (38.8% of 129) reached the low-density lipoprotein—cholesterol target of <2.0 mmol/L. This value of low-density lipoprotein—cholesterol is similar to that recommended by the American Heart Association/American College of Cardiology. With regard to the General Medical Services guidelines target for total cholesterol, 162 (73.6% of 220) patients reached ≤5.0 mmol/L. The group that best achieved target cholesterol (Joint British Societies' Guidelines and General Medical Services) were those with comorbidities. In conclusion, while reaching General Medical Services targets was satisfactory, the percentage of patients reaching Joint British Societies' Guidelines targets was not. This discrepancy may reflect the presence of multiple guidelines. The current stricter lipid targets are difficult to achieve; possible methods that may be used to improve lipids further could involve using combination therapy, statin dose titration, and better education.

Health Outcomes and Economic Impact of Therapy Conversion to a Biphasic Insulin Analog Pen Among Privately Insured Patients with Type 2 Diabetes Mellitus

STUDY OBJECTIVE

To evaluate claims-related treatment adherence, health care resource utilization, and associated costs of therapy conversion from an insulin vial and syringe to a premixed biphasic insulin analog pen device among privately insured patients with type 2 diabetes mellitus.

DESIGN

Retrospective, longitudinal, intrapatient (before and after) analysis.

DATA SOURCE

PharMetrics database of medical and pharmaceutical claims from 57 commercial health plans across the United States.

PATIENTS

Four hundred eighty-six adult patients with a confirmed diagnosis of type 2 diabetes who converted from an insulin analog vial and syringe (233 patients) or a human insulin vial and syringe (253 patients) to a biphasic insulin analog pen device between July 1, 2001 and December 31, 2002.

MEASUREMENTS AND MAIN RESULTS

All patients had no previous use of the pen device. Primary end points were medication possession ratio (MPR), a measure of adherence; hypoglycemic events; associations between treatment adherence and hypoglycemic events, and adherence and all-cause health care costs; and all-cause-attributable, hypoglycemia-attributable, and other diabetes-attributable costs. After conversion, MPR increased significantly from 59% to 68% (p<0.01). A significant decrease in the likelihood of experiencing a hypoglycemic event was also observed after conversion (odds ratio [OR] 0.40, 95% confidence interval [CI] 0.27-0.61, p<0.05), with hypoglycemic occurrences reduced nearly two thirds among subjects with optimal adherence indicated by an MPR of 80% or greater (incidence rate ratio 0.36, 95% CI 0.11-0.76, p<0.05). Significant decreases in hypoglycemia-attributable emergency department visits (OR 0.36, 95% CI 0.16-0.84, p<0.05) and physician visits (OR 0.39, 95% CI 0.20-0.77, p<0.05) were observed. Total mean all-cause annual treatment costs were reduced by $1748/patient (p<0.01), hypoglycemia-attributable costs were reduced by $908/patient (p<0.01), and other diabetes-attributable costs were reduced by $643/patient (p<0.01). Patients with an MPR of 80% or greater were associated with significant reductions in all-cause health care costs (OR 0.55, 95% CI 0.31-0.80, p<0.05).

CONCLUSION

Privately insured patients with type 2 diabetes may exhibit considerable improvements in clinical and economic outcomes after insulin therapy conversion from vial and syringe to a premixed biphasic insulin analog pen device.

Risk factors for rhabdomyolysis with simvastatin and atorvastatin

OBJECTIVE

To assess the frequency of risk factors for rhabdomyolysis with simvastatin and atorvastatin in cases reported to the Australian Adverse Drug Reactions Advisory Committee (ADRAC).

DESIGN

Reports meeting the definition of rhabdomyolysis were reviewed for risk factors including age > or = 70 years, dose > or = 40 mg, hepatic dysfunction, diabetes mellitus, hyperkalaemia, hypothyroidism and the use of concomitant interacting medications.

RESULTS

Only one report associated with simvastatin and five reports associated with atorvastatin did not list any risk factors for rhabdomyolysis. Interacting medicines featured in 77% of reports of rhabdomyolysis associated with simvastatin and 44% of reports associated with atorvastatin. A comparison of the age profile for reports of atorvastatin- and simvastatin-associated rhabdomyolysis with that for all adverse drug reaction reports received, and for all reports of muscle disorders, suggested a trend towards an increasing risk of rhabdomyolysis with increasing age with simvastatin but not with atorvastatin. Similarly, comparing prescribed tablet strengths from Pharmaceutical Benefits Scheme data with the HMG-CoA reductase inhibitor ('statin') doses in reports of rhabdomyolysis suggested a dose-related risk with simvastatin, but a less increased risk with high-dose atorvastatin.

CONCLUSION

Risk factors for rhabdomyolysis featured in nearly all of the reports of statin-associated rhabdomyolysis and the majority of reports listed multiple risk factors, although dependence on risk factors appeared to be stronger with simvastatin than atorvastatin. The multiplication of risk factors in patients taking simvastatin and atorvastatin should be minimised.

The cardiovascular patient's perceptions of complementary and alternative medicine

BACKGROUND

Complementary and alternative medicine (CAM) use is common among patients with cardiovascular disorders and is generally underrecognized by physicians. The attitudes of these patients regarding these therapies and their perceptions of safety and efficacy have not been well defined.

METHODS

A written survey was received from a cohort of outpatients seen at a large outpatient cardiovascular clinic in Texas. Over 75% of patients responded, with more than 90% of returned surveys adequate for analysis.

RESULTS

Of the 210 respondents 113 admitted to CAM use, with Vitamins E and C being the most frequently utilized agents. Women were significantly more likely to take CAM than men (69 vs. 46%, p = 0.002), particularly those taking hormone replacement therapy. Over half of patients surveyed stated their cardiologist was unaware of their use of CAM. Only 15% of patients felt that CAM was more efficacious than their traditional medications, but almost half felt it was significantly safer. A similar number were unaware of any interactions between CAM and their other medications.

CONCLUSIONS

Use of CAM is common in cardiology outpatients, and many patients remain unaware of potential health risks. Physicians should routinely question patients about use of CAM and attempt to educate users regarding potential health risks.

HDL-raising strategies in the treatment of coronary artery disease: perspectives from the Armed Forces Regression Study

PURPOSE OF REVIEW

Even with the aggressive reduction of LDL-cholesterol, the risk of cardiovascular events in patients with coronary artery disease remains substantial. The Armed Forces Regression Study was a randomized, double-blind, placebo-controlled trial of combination drug therapy aimed at raising HDL-cholesterol in patients with angiographically evident coronary artery disease. Drug therapy ultimately resulted in regression of the angiographic lesions and a reduction in cardiovascular events. This review places the Armed Forces Regression Study within the context of other recent studies.

RECENT FINDINGS

In the past few years a number of other important papers have further defined the important role HDL-cholesterol plays in the pathobiology of atherosclerosis. These studies have focused on three general areas: HDL-cholesterol metabolism and the reverse cholesterol transport pathway; novel therapeutic interventions and their effects on coronary artery disease as assessed through non-invasive imaging modalities; and finally a re-analysis of previous outcomes trials with established HDL-cholesterol modifying agents.

SUMMARY

The results of the Armed Forces Regression Study fit nicely within the evolving paradigm of targeting HDL-cholesterol in patients at risk of cardiovascular events. The use of niacin and well-tolerated fibrates as an adjunct to statins or as primary therapy in patients intolerant of statins appears reasonable in patients with low levels of HDL-cholesterol and at high risk of cardiovascular events. The further development of novel therapeutic approaches, in addition to broadening our pharmacological armamentarium, should further advance our understanding of HDL-cholesterol.