Abstract
BackgroundMany patients at very-high atherosclerotic cardiovascular disease risk do not reach guideline-recommended targets for LDL-C. There is a lack of data on real-world use of non-statin lipid-lowering therapies (LLT) and little is known on the effectiveness of fixed-dose combinations (FDC). We therefore studied prescription trends in oral non-statin LLT and their effects on LDL-C.MethodsA retrospective analysis was conducted of electronic medical records of outpatients at very-high cardiovascular risk treated by general practitioners (GPs) and cardiologists, and prescribed LLT in Germany between 2013 and 2018.ResultsData from 311,242 patients were analysed. Prescriptions for high-potency statins (atorvastatin and rosuvastatin) increased from 10.4% and 25.8% of patients treated by GPs and cardiologists, respectively, in 2013, to 34.7% and 58.3% in 2018. Prescription for non-statin LLT remained stable throughout the period and low especially for GPs. Ezetimibe was the most prescribed non-statin LLT in 2018 (GPs, 76.1%; cardiologists, 92.8%). Addition of ezetimibe in patients already prescribed a statin reduced LDL-C by an additional 23.8% (32.3 ± 38.4 mg/dL), with a greater reduction with FDC [reduction 28.4% (40.0 ± 39.1 mg/dL)] as compared to separate pills [19.4% (27.5 ± 33.8 mg/dL)]; p < 0.0001. However, only a small proportion of patients reached the recommended LDL-C level of < 70 mg/dL (31.5% with FDC and 21.0% with separate pills).ConclusionsPrescription for high-potency statins increased over time. Non-statin LLT were infrequently prescribed by GPs. The reduction in LDL-C when statin and ezetimibe were prescribed in combination was considerably larger for FDC; however, a large proportion of patients still remained with uncontrolled LDL-C levels.Graphic abstract
Highlights
LDL cholesterol (LDL-C) is a modifiable risk factor causally related to atherosclerotic cardiovascular disease (ASCVD) [1, 2]
Of the patients prescribed lipid-lowering therapies (LLT) in 2018, 97.2% were treated by general practitioners (GPs) and 2.8% by cardiologists
The most frequent cardiovascular risk factors in patients treated by GPs and cardiologists, respectively, were hypertension (81.7% and 74.7%), diagnosed hypercholesterolaemia based on the ICD-10 code (69.7% and 69.6%), and type 2 diabetes (54.3% and 29.6%). 11.2% and 10.1% had a history of an acute coronary syndrome, and 21.1% and 7.4% had a history of stroke or transient ischaemic attack
Summary
LDL cholesterol (LDL-C) is a modifiable risk factor causally related to atherosclerotic cardiovascular disease (ASCVD) [1, 2]. Major international guidelines recommend lowering of LDL-C to riskdependent goals to reduce ASCVD risk [3, 4] These treatment targets are only achieved in a minority of patients. In patients with high baseline LDL-C or in patients that cannot tolerate high statin doses, e.g., because of muscle symptoms [7], statin monotherapy may not be sufficient to attain the LDL-C target This underlines the need for additional nonstatin lipid-lowering therapies (LLT) such as ezetimibe [8]. Non-statin LLT were infrequently prescribed by GPs. The reduction in LDL-C when statin and ezetimibe were prescribed in combination was considerably larger for FDC; a large proportion of patients still remained with uncontrolled LDL-C levels
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