Overcoming Barriers to Statin Adherence

Abstract and Introduction

Abstract

Despite the increased use of statins as a result of expanding indications and guideline recommendations, lack of adherence remains a pervasive issue in medication management. Nonadherence to statins can lead to poor health outcomes, including cardiovascular disease–related emergency department visits, hospitalizations, healthcare costs, and mortality. Medication adherence is multifactorial, and a comprehensive approach is essential for optimization. Potential barriers to statin adherence include costs and adverse effects; interventions that pharmacists can employ include counseling and simplifying regimens.

Introduction

Cardiovascular disease (CVD) is the leading cause of death globally. In 2016, an estimated 17.9 million people died from CVD, accounting for 31% of global deaths, of which 85% were due to myocardial infarction (MI) and stroke.^[1] Statins, as 3-hydroxy-3-methylglutarylcoenzyme A reductase inhibitors are known, are commonly prescribed medications that are pivotal for preventing CVD and related events.^[2]

Medication adherence directly influences the extent to which statins prevent CVD events, including mortality (Table 1).^[2–7] Poor statin adherence can also increase CVD related emergency department visits, hospitalizations, and healthcare costs.^[6,7] A 10% reduction in statin-medication possession ratio is associated with a 5% increased risk for CVD-related hospitalizations.^[7] Furthermore, nonadherence over 1 year is associated with a $400 to $900 per patient higher total healthcare cost in the subsequent 18 months. Despite well-documented benefits, statins are underused, and adherence remains suboptimal. Approximately 50% of patients discontinue statin therapy within 1 year, and adherence decreases over time.^[4,6]

Table 1. Retrospective Cohort Studies of Statin Adherence and Mortality
Number of Patients		Duration (years)	All-Cause Mortality Outcomes
347,104	Veterans with ASCVD	1.25	MPR <50% vs. MPR ≥90%: HR 1.30; 95% CI, 1.27–1.34
90,869	Medicare beneficiaries post–MI hospitalization	1	PDC <80% vs. PDC ≥80%: HR 1.26; 95% CI, 1.15–1.38
229,918	Adults without and with CHD	4 5	PDC <10% vs. PDC ≥90% Primary prevention: HR 1.46; 95% CI, 1.40–1.52 Secondary prevention: HR 1.52; 95% CI, 1.49–1.55
31,455	Elderly MI survivors	2.4	PDC <40% vs. PDC ≥80%: HR 1.25; 95% CI, 1.09–1.42

ASCVD: atherosclerotic cardiovascular disease; CHD: coronary heart disease; CI: confidence interval; HR: hazard ratio; MI: myocardial infarction; MPR: medication possession ratio; PDC: proportion of days covered.
Source: References 2–5.

Table 2. Statin Intolerance Prevention and Management Strategies
Prevention	Management
Initiate hydrophilic statins (rosuvastatin, pravastatin, fluvastatin), especially if intolerance risk factors exist^a	Switch to a different statin
Evaluate for and treat other causes or contributors to intolerance symptoms^b	Reduce statin dose or administration frequency
Pharmacogenetic testing	Treat other causes or contributors to intolerance symptoms^b
	Add or switch to a nonstatin^c

^a Examples: elderly, renal disease, SLCO1B1*5 variant.
^b Examples: hypothyroidism, vitamin D deficiency, dehydration, drug interactions.
^c Examples: ezetimibe, proprotein convertase subtilisin/kexin type 9 serine protease inhibitor, fibrate, omega-3 fish oil, bile acid sequestrant.
Source: References 24–28.

Table 3. Statin-Adherence Support Interventions
Medication reconciliation	Monitoring lipid concentrations
Simplifying regimens	Alternate dosing
Patient education (face-to-face or telephone)	Minimize/manage intolerance
Reducing cost	Vitamin D supplementation
Motivational interviewing	Pharmacogenetic testing
Alarms or reminders	Automated voice or text messaging
90-day supplies	Home visits
Mail order	Postdischarge follow-up
Automatic refills, synchronization	Incentives
Adherence packaging	Identify CV risk patients or those with predictors for nonadherence
Combination pills (e.g., amlodipine-atorvastatin, simvastatin-ezetimibe)	Assay concentration monitoring

CV: cardiovascular. Source: References 9, 10, 13, 17–19, 21, 24–28, 31–34, 38–41, 43–45, 47–49.

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Overcoming Barriers to Statin Adherence

Abstract and Introduction

Abstract

Introduction

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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