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Effectiveness of antihyperlipidemic drug management in clinical practice
S E Andrade1, G M Saperia, M L Berger
1Department of Applied Pharmaceutical Sciences, University of Rhode Island, Kingston 02881, USA.
Insights
Antihyperlipidemic drugs did not reduce coronary heart disease hospitalizations in a real-world study. Poor adherence and failure to reach goal low-density lipoprotein cholesterol (LDL-C) levels were key issues.
Area of Science:
- Cardiology
- Public Health
- Pharmacoeconomics
Background:
- Randomized clinical trials demonstrate antihyperlipidemic drug efficacy.
- Real-world effectiveness may be limited by drug discontinuation and suboptimal lipid level achievement.
- Coronary heart disease (CHD) hospitalization rates are a critical outcome measure.
Purpose of the Study:
- To compare CHD and non-CHD hospitalization rates during and after antihyperlipidemic drug therapy.
- To assess low-density lipoprotein cholesterol (LDL-C) levels in relation to antihyperlipidemic drug use and discontinuation.
- To evaluate the real-world effectiveness of lipid-lowering therapy in a community setting.
Main Methods:
- Retrospective cohort study of 2369 patients across two health maintenance organizations (HMOs) from 1988 to 1994.
- Comparison of hospitalization rates and LDL-C levels during periods of drug use versus nonuse.
- Statistical control for patient demographics, medical history, and HMO site.
Main Results:
- No significant reduction in CHD hospitalization rates was observed during antihyperlipidemic drug use (Rate Ratio = 1.02).
- Non-CHD hospitalization rates were significantly lower during drug use (Rate Ratio = 0.70).
- Only 27% of patients with a history of CHD achieved LDL-C <130 mg/dL during therapy, compared to 18% during gaps.
Conclusions:
- Antihyperlipidemic therapy failed to demonstrate effectiveness in reducing CHD hospitalizations in this community-based study.
- Suboptimal patient adherence and inadequate LDL-C goal attainment undermine real-world treatment effectiveness.
- Interventions are needed to improve patient compliance and lipid disorder management.
Abstract:
Although randomized clinical trials have convincingly shown the efficacy of antihyperlipidemic drugs, both discontinuation of antihyperlipidemic drugs and failure to achieve goal lipid levels would be expected to attenuate the effect of these drugs on reducing the rates of hospitalization for coronary events. This study compares the rates of hospitalization and low-density lipoprotein cholesterol (LDL-C) levels during and after discontinuation of antihyperlipidemic drug therapy. A retrospective cohort study was conducted among 2369 patients at 2 health maintenance organizations (HMOs) during the period 1988 to 1994. Rates of coronary heart disease (CHD)-related hospitalization and non-CHD-related hospitalization and the LDL-C levels between 14 and 180 days after the initiation or discontinuation of drug therapy were compared for periods of antihyperlipidemic drug use and nonuse. The rate ratio for CHD hospitalization during periods of antihyperlipidemic drug use compared with periods of nonuse was 1.02 (95% CI, 0.74 to 1.40), excluding the first 6 months after initiation or discontinuation and controlling for patient sex, age, history of CHD, hypertension, diabetes, and HMO site. By contrast, the adjusted rate ratio was 0.70 (95% CI, 0.61 to 0.80) for non-CHD hospitalization. The percentage of patients with a history of CHD who achieved LDL-C levels <130 mg/dL was 27% < or =6 months after initiation of antihyperlipidemic drug therapy compared with 18% during gaps in drug therapy (P = 0.04). This study failed to demonstrate the effectiveness of lipid-lowering therapy in reducing CHD hospitalizations in community settings, apparently because most recipients either discontinued therapy or failed to achieve the desired LDL-C reduction while receiving therapy. These results indicate the need for interventions to improve patient compliance and management of lipid disorders.