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July 23, 2002 — Sustained, long-term use of statins (cholesterol-lowering drugs) in elderly patients is low, according to an article published in the July 24/31 issue of The Journal of the American Medical Association(JAMA).
Joshua S. Benner, Pharm.D., Sc.D., of Brigham and Women's Hospital and Harvard Medical School, and colleagues studied changes in statin use over time and looked for characteristics that could be used to predict poor long-term statin use in 34,501 patients aged 65 and older who were enrolled in the New Jersey Medicaid and Pharmaceutical Assistance to the Aged and Disabled (PAAD) programs. Patients started using statins between 1990 and 1998 and were followed up until death, program disenrollment or December 31, 1999, whichever occurred first. Statin use was measured every three months for the first year of the study and every six months after that.
According to background information given in the article, cardiovascular disease accounts for 950,000 deaths annually in the United States and includes 460,000 deaths from coronary heart disease (CHD). Eighty-five percent of those who die of CHD and 72 percent of those who experience a stroke are 65 years of age and older. Previous studies have shown that statin therapy reduces morbidity and mortality related to coronary heart disease, with benefits in patients 65 years of age and older similar to benefits observed in younger patients.
The authors found that "The proportion of patients who were adherent with statin therapy was 60 percent, 43 percent, 26 percent and 32 percent after 3, 6, 60 and 120 months, respectively." They also found that "Long-term use was especially low for patients of black and other nonwhite races, regardless of socioeconomic status, as well as for recipients of Medicaid, regardless of race." The researchers also found that patients with CHD, a history of stroke, coronary heart failure, diabetes and hypertension had better adherence to statin therapy over the study.
The authors conclude, "Persistence with statin therapy in older patients declines substantially over time, with the greatest drop occurring within the first six months of treatment. Interventions are needed early in treatment and among high-risk group, including those who experience coronary heart disease events after initiating treatment."
Editor's Note: Dr. Benner was supported during this project by a National Research Service Award from the U.S. Agency for Healthcare Research and Quality and Harvard School of Public Health. This study was also funded in part by research grants from the National Institute on Aging. For author's full disclosure information, see the JAMA article.
Elderly patients prescribed statins for existing coronary conditions or as a preventive therapy are likely to stop taking their drugs within two years, according to another article published in the July 24/31 issue of The Journal of the American Medical Association (JAMA).
According to background information given in the article, "Statins have been shown to significantly reduce morbidity and mortality in patients with coronary artery disease (CAD) and in patients with hyperlipidemia but only if taken on a regular basis." Previous clinical studies have looked at adherence to statin therapy for short periods of time, but benefits are usually only seen after one to two years of continuous treatment.
Cynthia A. Jackevicius, B.Sc.Phm., of Toronto General Hospital (Ontario, Canada), and colleagues studied data from 143,505 patients aged 66 years old and older who received at least one statin prescription between January 1994 and December 1998 gathered from various health care databases in Ontario, Canada. Patients were divided into three groups: those with recent acute coronary syndrome (ACS) (n=22,379), those with chronic coronary artery disease (CAD) (n=36,106), and those without any coronary disease who were prescribed statins as a preventive therapy (n=85,020). All patients did not have a statin prescription in the year prior to inclusion in the study, and were followed up for two years after their first statin prescription.
The researchers found that two-year adherence to statin therapy was only 40.1 percent in the ACS group, 36.1 percent in the chronic CAD group, and 25.4 percent for the primary prevention group. They also found that "... patients with existing coronary disease, and those with comorbidities (diabetes, hypertension) were the most likely to be adherent to therapy. While those with acute or chronic cardiac disease fared better, at two years, less than 50 percent of patients were adherent to therapy for a sufficiently long duration to possibly achieve substantial morbidity and mortality benefits."
The authors suggest that future efforts to help increase adherence to statin therapy involve the initiation of therapy in the hospital, ongoing reminders during physician office visits and detailed patient education programs.
Editor's Note: This study was supported by an operating grant to the Canadian Cardiovascular Outcomes Research Team from the Canadian Institutes of Health Research and the Heart and Stroke Foundation. Dr. Tu is supported by a Canada Research Chair in Health Services Research. Dr. Jackevicius receives honoraria for continuing education from Merck, Pfizer, and Bayer.
Editorial: Elderly Patients and Adherence to Statin Therapy
In an accompanying editorial, William B. Applegate, M.D., M.P.H., of Wake Forest University Health Sciences in Winston-Salem, NC, writes "Despite different methods of defining adherence, the findings of the two studies are remarkably consistent and alarming given the efficiency of statins in reducing cardiovascular morbidity. In both studies, adherence to statin therapy declined more than 25 percent in the first six months after the original prescription, with further declines in adherence the longer the cohort [study group] was followed."
Dr. Applegate writes that these results are alarming and have important public health implications for elderly patients. He concludes that, "Physicians and health systems need to emphasize the importance of persistence with therapy over time for all patients. Because elderly patients are at least as likely to benefit from statin therapy as younger patients and are more likely to discontinue medications, particular attention should be paid to initiating statin therapy in elderly persons who present with coronary syndromes or their equivalent."