Abstract
BackgroundClinical trials have demonstrated that either initiating or up-titrating a statin dose substantially reduce Low-Density Lipoprotein-Cholesterol (LDL-C) levels. However, statin adherence in actual practice tends to be suboptimal, leading to diminished effectiveness. This study aims to use real-world data to determine the effect on LDL-C levels and LDL-C goal attainment rates, when selected statins are titrated in Asian patients.MethodsA retrospective cohort study over a 5-year period, from April 2014 to March 2019 was conducted on a cohort of multi-ethnic adult Asian patients with clinical diagnosis of Dyslipidaemia in a primary care clinic in Singapore. The statins were classified into low-intensity (LI), moderate-intensity (MI) and high-intensity (HI) groups according to the 2018 American College of Cardiology and American Heart Association (ACC/AHA) Blood Cholesterol Guidelines. Patients were grouped into “No statin”, “Non-titrators” and “Titrators” cohorts based on prescribing patterns. For the “Titrators” cohort, the mean percentage change in LDL-C and absolute change in LDL-C goal attainment rates were computed for each permutation of statin intensity titration.ResultsAmong the cohort of 11,499 patients, with a total of 266,762 visits, there were 1962 pairs of LDL-C values associated with a statin titration. Initiation of LI, MI and HI statin resulted in a lowering of LDL-C by 21.6% (95%CI = 18.9–24.3%), 28.9% (95%CI = 25.0–32.7%) and 25.2% (95%CI = 12.8–37.7%) respectively. These were comparatively lower than results from clinical trials (30 to 63%). The change of LDL-C levels due to up-titration, down-titration, and discontinuation were − 12.4% to − 28.9%, + 13.2% to + 24.6%, and + 18.1% to + 32.1% respectively. The improvement in LDL-C goal attainment ranged from 26.5% to 47.1% when statin intensity was up-titrated.ConclusionIn this study based on real-world data of Asian patients in primary care, it was shown that although statin titration substantially affected LDL-C levels and LDL-C goal attainment rates, the magnitude was lower than results reported from clinical trials. These results should be taken into consideration and provide further insight to clinicians when making statin adjustment recommendations in order to achieve LDL-C targets in clinical practice, particularly for Asian populations.
Highlights
Clinical trials have demonstrated that either initiating or up-titrating a statin dose substantially reduce Low-Density Lipoprotein-Cholesterol (LDL-C) levels
A total of 11,499 unique patients with Dyslipidaemia and 21 years or older were extracted from the polyclinic electronic medical records (EMR), consisting a total of 266,762 visits. 9661 of them (84.0%) had at least two LDL-C values over the study period
Contrary to trial data on incremental statin dose-related LDL-C lowering effect [31], the results reveal that LDL-C reduction is lower when HI statin is initiated compared to the commencement of LI and MI statin therapy
Summary
Clinical trials have demonstrated that either initiating or up-titrating a statin dose substantially reduce Low-Density Lipoprotein-Cholesterol (LDL-C) levels. Statin initiation has been shown to effectively reduce LDL-C levels by between 30 to 63%, while the doubling of dose further decreases it by 6% [10,11,12,13,14,15] Given that these trials enrolled subject based on stringent eligibility criteria and reported on predominantly Caucasian populations, it remains uncertain if the magnitude of LDL-C lowering differ in actual clinical practice due to suboptimal medication adherence, variability in patient demographic characteristics, psychosocial profiles and health-seeking behaviour [16, 17]. No further analysis was conducted on LDL-C reduction for uptitration of different formulations of statin across different intensity levels
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