Potential impact on cardiovascular public health of over-the-counter statin availability

Over-the-counter (OTC) statin availability has been hypothesized to represent a strategy for treating consumers at moderate risk of coronary heart disease (CHD) who are currently not receiving drug therapy. The viability of this strategy has been questioned, particularly with respect to the public health benefit that can be obtained in an unsupervised treatment environment. The previously reported Consumer Use Study of Over-the-Counter Lovastatin (CUSTOM) examined consumer behavior in a simulated OTC setting in which 20 mg lovastatin could be purchased. Framingham CHD risk scores were calculated for 981 self-selected consumers who used OTC lovastatin in CUSTOM. Overall, this group had a median 10-year CHD risk of 10%, but with significant numbers of consumers with estimated risks of <5% and >20%. According to the risk profile of CUSTOM consumers, the use of 20 mg lovastatin for 10 years would be expected to prevent approximately 33,100 CHD events per 1 million users. This represents a 10-year number needed to treat of 30 consumers. This optimal benefit may be reduced because some higher risk consumers in CUSTOM used lovastatin rather than appropriate, more aggressive supervised care. On the basis of the frequencies of diversion from optimal care observed in CUSTOM, the number of events prevented might be reduced to 23,000 (number needed to treat 43 consumers). Sensitivity analyses have demonstrated that these estimates are robust and that the predicted public health benefit likely falls in the range of 23,000 to 33,000 CHD events prevented per 1 million treated for 10 years. In conclusion, on a population basis, OTC statin availability is likely to result in clinically meaningful reductions in CHD morbidity and mortality. The analyses also identified opportunities for optimizing the use of OTC statins in the marketplace.