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Statins Are Underused and Underdosed!

Posted: Thursday, March 18, 2004

A retrospective analysis of data from patients with non-ST segment acute coronary syndromes suggests that in clinical practice statins are routinely underdosed — thus, significant numbers of patients never receive the "protective" benefit of statins, according to findings reported at the American College of Cardiology 2004 Annual Scientific Session.

Senior study author Christopher P. Cannon, MD, associate professor at Harvard Medical School in Boston, Massachusetts, stated that consistent underdosing occurred despite the fact that patients were entered into a clinical study (TACTICS-TIMI 18) and were being carefully followed. The typical pattern for statin therapy, he said, is that patients are started at a low dose with the intent of titrating upward to the doses associated with reduced risk of cardiovascular events, for example, 40 mg of simvastatin or pravastatin.

"What happens, I think, is that after patients are started on statins, the follow-up is lacking," Dr. Cannon said. Part of the problem is the mechanics of statin management — the need for fasting blood work to determine serum cholesterol levels. "Often that blood work is only available days after the patient was in seen in the office. When the report comes in, typically it is noted, a letter is sent out and then the results tend to fall through the cracks." One way to improve statin dosing "might be to order blood tests before office visits so that you have the results in hand when the patient is face-to-face with you," Dr. Cannon said.

Sidney C. Smith Jr., MD, professor of medicine and director of the Center for Cardiovascular Science and Medicine at the University of North Carolina in Chapel Hill, stated that the findings are discouraging. "Still a decade after a Nobel prize was awarded for work leading to statin therapy, and after years of emphasizing the importance of statins, our patients remain either untreated or undertreated. We are missing an important opportunity to improve outcomes." Dr. Smith was not involved in the study.

In the study, Dr. Cannon and colleagues analyzed data from 2,220 patients enrolled in the TACTICS-TIMI 18 trial. All patients had non-ST elevation acute coronary syndromes. At the time of study entry, a third of the patients were receiving statins. Thirty-five percent of the patients (n = 132) were receiving atorvastatin, 34% (n = 126) were receiving simvastatin, 16% were receiving pravastatin, and 15% other statins.

But only 17% of the patients receiving simvastatin and 36% of patients taking pravastatin were "treated with the 40-mg doses shown in clinical trials to be effective at reducing cardiovascular events," Dr. Cannon said. Fifty-seven percent of patients receiving pravastatin and 44% of the patients taking simvastatin were receiving just 20 mg daily — half the dose used in clinical trials. Just 1% of patients were receiving aggressive lipid-lowering therapy with 80 mg of atorvastatin.

Moreover, just 47% of the patients receiving statin therapy at study entrance had low-density lipoprotein cholesterol levels of 100 mg/dL or less. Six months after study entry, 51% of the 2,220 patients were receiving statin therapy but "the doses of statins were no higher than the low doses used at baseline," Dr. Cannon said.

Raphaelle Dumaene, MD, a research fellow at Harvard Medical School, told Medscape that she thinks the findings of the study "probably underestimate the problem of underdosing statins. In clinical practice, I think this is likely to be much more common.... One reason is that clinicians may want to keep the dose low to keep costs down for the patient."

That practice is bad medicine and bad economics, Dr. Dumaene said, because low-dose statins do not offer the cardiovascular disease protection of higher-dose statins, so the patients have not reduced their risk of cardiovascular events. Treatment of acute events, she said, effectively trumps the cost of drug therapy. Dr. Dumaene was not involved in the study.

Source: Diabetes In Control.com