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10个糖尿病患者中有6个服用他汀类药物,但他们都应该吗?  

2016-09-21 11:32:03|  分类: 疾病与治疗 |  标签: |举报 |字号 订阅

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Two in five adult diabetic patients without cardiovascular disease in a national registry of cardiology outpatient practices were not prescribed a statin. Moreover, statin prescribing varied widely across these practices, US researchers report.

The study, by Yashashwi Pokharel, MD, MSCR, formerly from the Methodist DeBakey Heart and Vascular Center in Houston, Texas, and now at Saint Luke's Mid America Heart Institute in Kansas City, Missouri, and colleagues, was published as a research letter in the September 20 issue of the Journal of the American College of Cardiology.


A diabetic patient with no history of myocardial infarction or stroke may have been referred to a cardiology clinic for acute chest pain that turned out to be unrelated to CVD, senior author Salim S Virani, MD, PhD, from Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, explained to Medscape Medical News.

The takeaway message for endocrinologists, cardiologists, and family practitioners is "whoever comes in contact with these patients [should] make sure that [they] are receiving preventive therapies, and a statin is one of the most important," according to Dr Virani.

Clinicians should "always look at the long-term horizon," he continued, because these diabetic patients are at very high risk of having a heart attack or stroke.

On the other hand, says endocrinologist Kasia J Lipska, MD, MHS, of Yale School of Medicine, New Haven, Connecticut, "I think our goal as endocrinologists is not to necessarily put every single patient on a statin; our goals should be to discuss the benefits and harms of statin therapy with patients and help them make…decisions about [this] therapy…that are right for them.

Dr Lipska told Medscape Medical News she likes to use the statin decision aid developed by the Mayo Clinic when discussing this topic with patients.

Greater-Than-Expected Prescribing Variation

Although guidelines recommend giving diabetic patients statins to reduce their risk of CVD and CVD mortality, little is known about practice-level variations in statin prescribing, according to Dr Pokharel and colleagues.


They examined statin prescribing for 215,193 diabetic patients in the Practice Innovation and Clinical Excellence (PINNACLE) registry who were 40 to 75 years old when they were seen in 204 US cardiology practices from May 2008 to October 2013. Type of diabetes was not specified.

A total of 62% of diabetic patients were prescribed a statin.

Whether a patient would receive a statin varied by up to 57% across practices — after adjustment for age, gender, race, hypertension, dyslipidemia, tobacco use, nonstatin lipid-lowering therapy, and insurance coverage.


There will always be some patient-treatment variation between clinical practices, said Dr Virani, adding that variation that is less than 20% is generally considered to be acceptable. In a previous study the researchers found this level of prescribing discrepancy in VA hospitals, which suggests that care there is more uniform (Clin Cardiol. 2016;39:185–191).

During the study period, the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines recommended a target LDL-cholesterol level of 100 mg/dL, and the new American College of Cardiology/American Heart Association guidelines, without a target LDL level, came into effect in early November 2013, Dr Virani noted.

However, even in the subset of patients who attained a target LDL-cholesterol <100 mg/dL, statin prescribing for similar types of patients seen in different practices varied by 47%.

Prescribing Inertia vs Patient Reluctance, Intolerance

"I think a similar, or even wider, variation may be expected in endocrinology practices," Dr Lipska speculated. "Clinicians are missing an opportunity to manage cardiovascular risk factors better — that's certainly likely to be a big part of this," she noted.


However, in her experience, "patients are reluctant to start therapy because they often know someone who has had muscle aches or other side effects from statins, [or they may be] on multiple medications and reluctant to start yet another one," she said. And some patients who do start the therapy may be statin intolerant.

Importantly, patients with diabetes have different levels of other CVD risk factors, Dr Lipska pointed out.

"For some…the absolute risk reduction with statin therapy will be substantial," she said. "For others, it may be not be as big, [and] based on their personal values and preferences, the possible side effects of treatment may outweigh the benefits."


Only 13% of patients who were not on a statin were taking another lipid-lowering therapy (such as ezetimibe [Zetia, Merck] or niacin); however, 28% of patients on a statin were also receiving a nonstatin lipid-lowering therapy — suggesting that these patients were receiving more aggressive care, said Dr Virani.

Compared with patients who were not on a statin, those on a statin also had a lower mean LDL-cholesterol level: 90 mg/dL vs 103 mg/dL, respectively.

Other studies have reported that 5% to 20% of patients who are prescribed a statin are intolerant to it, most often due to muscle aches and pains, according to Dr Virani. So patient intolerance may explain part of the 38% of patients who were not receiving a statin, but it cannot account for all of it. "There's probably some clinical inertia," he acknowledged.


Thus, "identifying characteristics of high-performing practices and barriers at low-performing practices may help improve statin use in this high-risk population," Dr Pokharel and colleagues conclude.

The study was supported by the 2015–2016 American Medical Association Foundation Seed Grant Award. Dr Pokharel has been supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health. Dr Virani has been supported by the American Heart Association beginning grant-in-aid and the American Diabetes Association Clinical Science and Epidemiology award and has served on the steering committee (no financial remuneration) for the Patient and Provider Assessment of Lipid Management (PALM) Registry at the Duke Clinical Research Institute. Disclosures for the coauthors are listed in the article.

 

Marlene Busko

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