Many patients needing statins don’t take them

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Many patients with dangerously high cholesterol or a genetic predisposition to it don’t take statin drugs that can lower cholesterol, a US study suggests. Statins were being taken by just 52% of adults with what’s known as familial hypercholesterolemia, a genetic disorder that causes extremely high cholesterol and an increased risk of early cardiovascular disease. And only 38% of adults with non-genetic severe dyslipidemia took statins.

“All of these adults should be on a statin,” lead study author Dr. Emily Bucholz of Boston Children’s Hospital said.

Heart specialists recommend that people take statins when they have levels of low-density lipoprotein (LDL) – the bad kind of cholesterol that builds up in blood vessels and can lead to blood clots and heart attacks – of at least 190 milligrams per deciliter of blood. Commonly prescribed statins include atorvastatin (Lipitor), lovastatin (Mevacor), simvastatin (Zocor) and rosuvastatin (Crestor).

For the study, researchers examined survey data collected from 1999 to 2014 from US adults age 20 and over. Overall, less than 1% of adults had a family history of severely elevated cholesterol, and about 6.6% had the condition themselves, researchers report.

Older adults, people with insurance, and patients diagnosed with high blood pressure or diabetes were more likely to take statins for dangerously elevated cholesterol or a family genetic risk for the condition, the study found. Young people, and patients without insurance or a regular source of care, were less likely to take statins.

Statin use did increase among high-risk patients during the study period. The proportion of people with severely elevated cholesterol taking statins increased from 29% to 48% during the study, mirroring an overall trend for statin use in the general population. Only about 30% of patients took high-intensity statins – higher doses recommended for people at the greatest risk for health problems associated with dangerously high cholesterol levels.

The report says one limitation of the study is that researchers lacked data to see whether patients failed to take statins that were prescribed or if doctors didn’t give prescriptions, the authors note. Some patients might have tried statins and stopped using the drugs because of side effects like muscle aches.

“This study highlights a need for further study of the reasons for the mismatch between dyslipidemia screening and treatment,” said Dr Ian Kronish, of the Centre for Behavioural Cardiovascular Health at Columbia University Medical Centre in New York City. “We need a better understanding as to whether the low rates of treatment are being driven by clinical inertia – that is, providers are not recommending statins in eligible patients, or whether low treatment is due to patient disagreement or non-adherence to treatment recommendations,” Kronish, who wasn’t involved in the study.

If physicians don’t recommend statins to patients with high cholesterol, they should get a second opinion from another doctor, advised Dr Robert Eckel, of the University of Colorado Denver Anschutz Medical Campus. While statins are a good first choice, if these drugs don’t work or have intolerable side effects, patients can also try alternative drugs like ezetimibe (Zetia), colesevelam (Welchol) or newer, more expensive drugs in a family of medicines known as PCSK9 inhibitors.

“Once treated, this should be lifelong,” Eckel, a past president of the American Heart Association who wasn’t involved in the study.

Abstract
Background: Familial hypercholesterolemia (FH) and other extreme elevations in low-density lipoprotein cholesterol significantly increase the risk of atherosclerotic cardiovascular disease; however, recent data suggest that prescription rates for statins remain low in these patients. National rates of screening, awareness, and treatment with statins among individuals with FH or severe dyslipidemia are unknown.
Methods: Data from the 1999 to 2014 National Health and Nutrition Examination Survey were used to estimate prevalence rates of self-reported screening, awareness, and statin therapy among US adults (n=42 471 weighted to represent 212 million US adults) with FH (defined using the Dutch Lipid Clinic criteria) and with severe dyslipidemia (defined as lowdensity lipoprotein cholesterol levels ≥190 mg/dL). Logistic regression was used to identify sociodemographic and clinical correlates of hypercholesterolemia awareness and statin therapy.
Results: The estimated US prevalence of definite/probable FH was 0.47% (standard error, 0.03%) and of severe dyslipidemia was 6.6% (standard error, 0.2%). The frequency of cholesterol screening and awareness was high (>80%) among adults with definite/probable FH or severe dyslipidemia; however, statin use was uniformly low (52.3% [standard error, 8.2%] of adults with definite/probable FH and 37.6% [standard error, 1.2%] of adults with severe dyslipidemia). Only 30.3% of patients with definite/probable FH on statins were taking a high-intensity statin. The prevalence of statin use in adults with severe dyslipidemia increased over time (from 29.4% to 47.7%) but not faster than trends in the general population (from 5.7% to 17.6%). Older age, health insurance status, having a usual source of care, diabetes mellitus, hypertension, and having a personal history of early atherosclerotic cardiovascular disease were associated with higher statin use.
Conclusions: Despite the high prevalence of cholesterol screening and awareness, only ≈50% of adults with FH are on statin therapy, with even fewer prescribed a high-intensity statin; young and uninsured patients are at the highest risk for lack of screening and for undertreatment. This study highlights an imperative to improve the frequency of cholesterol screening and statin prescription rates to better identify and treat this high-risk population. Additional studies are needed to better understand how to close these gaps in screening and treatment.

Authors
Emily M Bucholz, Angie Mae Rodday, Katherine Kolor, Muin J Khoury, Sarah D de Ferranti

 

Figures from the UK suggest that more than 150,000 patients a year at risk of developing heart disease are not being given statins, says a Daily Mail report. Four in five of those who took part in the NHS Health Check scheme since 2013 were found to need the cholesterol-reducing drug but were not prescribed it, according to figures released by Public Health England.

The report says the Health Check was launched in 2009 to help prevent heart disease among middle-aged people not yet showing symptoms. But even though between 50% and 80% of cardiovascular disease (CVD) diagnoses may be classed as “preventable”, an estimated 162,000 people a year are not receiving the right treatment.

According to guidelines set by the National Institute for Health and Care Excellence, a patient should be prescribed statins if they have at least a 10% chance of having a heart attack in the next ten years. But, the report says, while around 3.9m Britons are at least 20% at risk of developing CVD, less than half are given statins. Around one in seven people are currently taking statins, according to NHS Digital.

Professor Helen Stokes-Lampard, chair of the Royal College of GPs, is quoted in the report as saying: “The College has concerns about the efficacy of blanket NHS health checks, such as the potential for over-diagnosis of patients, and particularly at a time when general practice is under intense resource and workforce pressures.”

Dr Matt Kearney, of NHS England, said: “The decision to prescribe what is likely to be a daily medication for life is complex and based on each patient’s individual circumstances.”

Francesco Cappuccio, president of the British Hypotension Society, underwent the Health Check himself and criticised the scheme as “formulaic” and “ridiculous”. He is quoted as saying: “The Health Check was designed exactly to catch the difficult-to-catch people, but these numbers (prescription of statins) are very, very low.

“Once you already have symptoms of these conditions, it can already be too late.”

In March it was reported a record 1.1bn prescriptions were handed out last year – an increase of nearly 40% in a decade.

Figures show statins, high blood pressure and heart failure drugs, and antidepressants are most common. Prescriptions for cholesterol-lowering statins have risen by 53% in a decade, with 72.6m given out last year. There were also 71.5m for high blood pressure and heart failure drugs – up 33% over the same period.

Health watchdog Nice said its new guidelines would recommend that millions more be offered high blood pressure pills – as it did for statins in 2014.

Reuters report
Circulation abstract
Daily Mail report
Public Health England report


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