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Do we really use statins adequately?

Session presentations
Cardiovascular Pharmacology and Pharmacotherapy

In the first presentation, Dr. Mohaupt explained that statins are prescribed because they can reduce LDL cholesterol by 20 to 60%, and increase HDL cholesterol by 50 to 10%. Why are statins not so good? On the one hand, there are different pharmacokinetic differences between molecules, and on the other hand, they can have side effects on the liver, kidney etc. Furthermore, he emphasised their potential deleterious effects on muscle tissue. This effect could range from being asymptomatic, to symptoms such as weakness, myalgia, myositis, and at the worst end of the spectrum, rhabdomyolysis. The symptoms of these effects on the muscles could be independent of the CPK enzymes – i.e. patients with symptoms can have normal CPK values. When prescribing statins, physicians should take into account the possibility to reduce rhabdomyolysis and there are some specific risk factors that should be kept in mind, namely age, renal and hepatic function, and thyroid dysfunction. These factors can all promote rhabdomyolysis under statin therapy. These risk factors depend on the type of statin molecule chosen, and its dose. If there is pre-existing muscule disorders, or other coexisting disease (impaired renal or hepatic function or thyroid dysfunction), or family or genetic predisposition, for example. Concomitant medication should also be considered, as well as some foods, such as grapefruit, as these may interfere with statin therapy.

In the second presentation, Dr. Marazzi addressed the question of whether some patients may be receiving statins unnecessarily. Statins in general are a very beneficial class of drugs, in terms of LDL cholester, lower is better. This is valid for both primary and secondary prevention. Dr. Marazzi pointed out that statins are statistically significantly efficacious at preventing cardiovascular events, but their efficacy for the prevention of stroke and mortality in women is not proven. The decision to prescribe statins should be based in risk factors rather than on cholesterol levels. He underlined the relation between statins and diabetes, pointing out that high doses of statins can lead to the development of diabetes in one out of every 255 patients treated with high doses. The only patients who receive statins unnecessarily are those with no cardiovascular risk factors, and those who are intolerant to statins. He also emphasised what he calls “nutraceuticals” (nutrition + pharmaceuticals). In case of intolerance to statins, other strategies should be considered.

In the third presentation, Prof. Wood presented the European guidelines on cardiovascular disease prevention in clinical practice, released at the time of this congress, and also the ESC/EAS guidelines for the management of dyslipidemia issued in 2011. He explained the relation between lipids and cardiovascular risk, and the links between lipids and lifestyle, i.e. reduction of saturated fat and transfats in the diet, the interest of a high-fibre diet, and the use phytosterols. He further presented the different drugs available to reduce LDL cholesterol, namely statins, bile acid sequestrants, nicotin acid, cholesterol absorption inhibitors, fibrates etc. Statins are the first line therapy for treating dyslipidemias, and benefit from Class I, level of evidence A recommendations. He discussed lipids and targets, and pointed out that in very high risk patients, the target LDL should be <1.8 mmol/L (<70mg/dL), or a >50% reduction in base level. This is also a Class I, level of evidence A recommendation. In terms of therapeutic management, he spoke about the drug initiation, up-titration of the dose to achieve the target, and finally, adherence to therapy over time. He explained here the results of the Euro-Aspire III survey, showing that control of cholesterol is poor in practically all countries. Furthermore, Dr. Wood mentioned than when adherence to treatment is poor, mortality is significantly higher. He finished in saying that total risk management must include a change in lifestyle, management of risk factors (blood pressure, diabetes, obesity...) and the most important element is adherence to treatment.

Lastly, Dr. Sirnes also referred to the newly released prevention guidelines, as well as the dyslipidemia guidelines. He explained that cardiovascular risk estimates are part of a continuum. He emphasised that the categories of risk cover very high risk, high risk, moderate risk and low risk. He underlined the necessity to treat these patients and to achieve target LDL cholesterol levels. He added that lipid monitoring before starting treatment with statins was important, and is mentioned in the guidelines. After 8 weeks of statin therapy, results should be monitored to adjust dosing if necessary. Tests should be repeated at every titration. Once target levels are achieved, annual monitoring is recommended, unless there is a suspicion of inadequate adherence, in which case more regular follow-up is required.




Do we really use statins adequately?

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.