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In a submitted column, Dr. Gregory Weiss reflects on the importance of adherence to cholesterol-lowering medications and including statins in treatment regimens.
Statins as we know them were conceived in the late 1970’s and saw widespread use in the 1990s following several studies linking their cholesterol-lowering properties to dramatically lower cardiovascular mortality. While statins remain a cornerstone of cardiovascular event prevention, intolerance and adverse effects from the drugs can often lead to poor adherence to prescribed regimens.
Citing the importance of statin therapy, James Reston PhD, MPH and colleagues at multiple centers state, “Strategies to improve patients' tolerance of and adherence to statins are an important avenue of research for optimizing the effectiveness of dyslipidemia treatment.”1
Reston led an analysis and systematic review looking at the benefits and harms of interventions to improve tolerance and adherence to statins in patients at risk for cardiovascular disease (CVD). Their findings support an update to the 2014 U.S. Department of Veterans Affairs and Department of Defense Clinical Practice Guidelines for Cardiovascular Risk Reduction.
When looking at ways to improve adherence to such an important therapy it is helpful to understand the scope of the problem and consequences of non-adherence. Non-adherence rates to statin therapy have been cited as high as 50% and are associated with high rates of recurrent myocardial infarction and death.2,3 Reston states, “This critically important issue requires clinician awareness and ongoing clinical attention to achieve optimal health outcomes.”1
Understanding the reasons patients discontinue or curtail recommended statin treatments is crucial to developing strategies promoting adherence. The primary adverse effect associated with statin therapy remains a variety of muscle symptoms. However, patient concerns about side effects and risk are not strongly associated with reduced statin use.4
The results of this systematic review identify moderate-strength evidence for intensifying patient care including adherence counseling, providing an adherence tip sheet, and following up with a telephone call.1 As clinicians we know that these interventions may exceed practical limitations necessitating coordination with other parts of the health care system.
In addition to intensified patient care, medication discontinuation due to intolerance can be prevented by lowering the dose of the statin and adding other lipid-lowering agents such as ezetimibe or a nutraceutical to the regimen. Up to 60% of patients with coronary artery disease may reach their LDL-C goals utilizing this approach.5
A group of studies further provide evidence, albeit weak, that non-daily dosing and supplementation with vitamin D may aid in adherence.1 All in all the best shot at promoting adherence to statin therapy appears to be by providing a multicomponent intervention with some form of personalized follow-up either by phone or in person.1
Adherence to treatment plans has always been a concern in clinical medicine. That having been said, it has also been studied since the beginning of time. I can honestly say that I have reviewed hundreds of peer-reviewed studies looking at everything from adherence to medications to compliance with lifestyle modifications, physical therapy, and post-operative care. A common theme can be found in every instance, engagement.
Engagement in our patient’s care plan seems like an easy thing, after all, it is why we got into clinical medicine in the first place. However, if you work in a family practice where you need to see 40 to 50 patients a day just to keep the doors open, time is at a premium. The solution ranges from mail and telephone follow-up to midlevel provider collaboration.
In any case, time is the problem. The stakes are high and even though these VA/DOD guidelines are somewhat vague, we can all do more to engage our patients with CVD by simply talking to them about their statin therapy and making changes that work for them and achieve recommended LDL-C goals.