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Statin Utilization in Primary Prevention in Patients with Diabetes Mellitus in Hong Kong

Statin Utilization in Primary Prevention in Patients with Diabetes Mellitus in Hong Kong. Vivian Lee, Pharm.D. Assistant Professor School of Pharmacy The Chinese University of Hong Kong. Disease Prevalence and Risk.  Prevalence & incidence of diabetes mellitus (DM) in HK

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Statin Utilization in Primary Prevention in Patients with Diabetes Mellitus in Hong Kong

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  1. Statin Utilization in Primary Prevention in Patients with Diabetes Mellitus in Hong Kong Vivian Lee, Pharm.D. Assistant Professor School of Pharmacy The Chinese University of Hong Kong

  2. Disease Prevalence and Risk •  Prevalence & incidence of diabetes mellitus (DM) in HK • DM pts has 2-4 fold increase risk of developing CHD & stroke • DM = Coronary heart disease (CHD) risk equivalent* • 10-yr risk of CHD >20% • Low-density lipoprotein-cholesterol (LDL) goal for high-risk <2.6mmol/L Executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) JAMA 2001;285:2486-2497.

  3. Significance of this study • Use of primary prevention in diabetic patients is still suboptimal in local practice • Portion of patients attaining target LDL (<2.6mmol) is low • Observed reluctance among physicians in titrating up dosages of statins • Findings of this study are helpful in promoting rational use of statin therapy

  4. Objectives • Studying the role of statins in primary prevention of cardiovascular diseases in DM patients in HK • Comparing the treatment outcomes in DM patients taking statins vs no statins • Describing the resources utilization in DM patients prescribed statins

  5. Methods • Retrospective chart review • Study sites: RH & TWEH, 2 public hospitals in HK • Inclusion • DM, no history of CHD/stroke • F/U at RH/TWEH during 2002/03 • With (study group) or without (control group) lipid-lowering agent (LLA) • Exclusion • CHD, MI, stroke, severe HF, angina, peripheral vascular disease • Long-term disease (e.g. cancer, severe chronic airway disease)

  6. DM pts F/U at RH/TWEH during 2002/03 Pts with no h/o CHD (primary prevention) Pts with h/o CHD (secondary prevention excluded) Review medical charts Pts on LLA (study group) Pts not on LLA (control group) LLA= lipid lowering agent

  7. Methods • Primary outcome • CV events (MI, CHD, stroke) • Secondary outcome • All-cause mortality

  8. Methods • Investigation parameters • Proportion of pts taking statins • Cholesterol levels • Proportion of pts attaining cholesterol goal(i.e. <2.6mmol/L) • Choices of statins & dosage • Adverse drug effects related to statins • Occurrence of primary outcomes

  9. Results

  10.  Hx of CHD / stroke (n = 310)  Hx of CHD / stroke (n = 681) Excluded Chart n/a (n = 88) Chart a/v (n = 222) Excluded On LLAs (n = 75) Not on LLAs (n = 147) Patient Recruitment DM patients (n  1000)

  11. Patient Demographics

  12. Past Medical History

  13. Past Medical History • Under-diagnosis of dyslipidemia: • For patients not on LLAs: • 49.0% patients had LDL-C > 2.6 mmol/L • Among them, 40.3% had LDL-C > 3.4 mmol/L Patients were deprived of lipid-lowering treatment!

  14. Blood Pressure Control Worse BP control in the LLA group

  15. Glycemic Control Worse glycemic control in the LLA group

  16. Concurrent Medications

  17. Use of Lipid-lowering Agents

  18. Use of Lipid-lowering Agents

  19. Use of Lipid-lowering Agents

  20. Dosage Titration of Lipid-lowering Agents • Majority (n = 32, 68%) were maintained on the same dose. • A very small number (n = 4, 5%) had their dosages titrated upwards.

  21. Laboratory Assessments of Lipid Levels • No lipid levels within the 2-year study period: • On LLAs: n = 9 (12%) • Not on LLAs: n = 49 (33%) Inadequate Laboratory Monitoring!

  22. Laboratory Assessments of Lipid Levels

  23. Laboratory Assessments of Lipid Levels

  24. Laboratory Assessments of Lipid Levels

  25. Treatment Outcomes

  26. Treatment Outcomes

  27. Adverse Drug Reactions • Elevation in liver transaminases reported in 7 patients (9.3%) • Myopathy reported in one patient (1.3%) • Otherwise well-tolerated

  28. Conclusion • Diabetic population is at high risk of CV complications • Majority had unsatisfactory LDL levels • Less than 40% received primary prevention • Benefits of primary prevention was not well recognized in local practice • Problems in prescribing • Under-dosing of LLA • Lack of laboratory monitoring of cholesterol levels • Patients’ non-compliance • Need to establish and promote appropriate primary prevention in diabetic population

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