Trending Clinical Topic: Statins

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Statins are lipid-lowering drugs that rank among the most commonly prescribed drugs in the world. As such, any news related to their use usually generates great interest. Concerns over new guidelines, a scientific statement regarding statin intolerance, and recent studies exploring the impact of their use on various non-cardiac conditions have once again made statins the hottest clinical topic of the week. . The global prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing at an alarming rate. Now, new findings suggest that statins may be beneficial for treating NAFLD (see infographic).

Research presented at the annual International Liver Congress used data from the Rotterdam Elderly Study to examine the possible benefits of statins in people with nonalcoholic steatohepatitis (NASH). Beyond reducing the incidence of NAFLD, considering only a subset of patients with biopsy-proven NAFLD, statin use was associated with a 45% reduction in NASH ( odds ratio [OR]0.55; P = 0.031). The researchers determined that statins could reduce the formation of lipid droplets and influence the expression of important inflammatory genes. Experts suggest more research is needed. “As far as I know, there is no strong evidence from large randomized trials to suggest that statins reduce the risk of NAFLD or improve its surrogate markers such as ALT or GGT. [gamma-glutamyltransferase] levels,” commented Naveed Sattar, PhD, in an interview.

Beyond the potential benefits of statins, intolerance remains a concern. The US National Lipid Association (NLA) recently released a new scientific statement on the management of patients with statin intolerance. The statement notes that although statins are generally well tolerated, intolerance is reported in 5-30% of patients. To identify a tolerable diet, the NLA recommends using several different strategies (different statin, dose and/or frequency of administration). To establish intolerance, a minimum of two statins should be attempted, including at least one at the lowest approved daily dose. In high- and very high-risk patients who are intolerant, the statement suggests initiating statin-free therapy while additional attempts are made to identify a tolerable statin, to limit exposure time to high levels of lipoproteins atherogenic.

A different set of statin recommendations has recently garnered strong backlash. New risk thresholds used to guide statin therapy for primary prevention of atherosclerotic cardiovascular disease in the 2021 European Society of Cardiology (ESC) guidelines significantly reduce eligibility for statin use, study finds in low-risk countries. An editorial that accompanied the results described them as “alarming” and said that, if confirmed, the guidelines should be reviewed to “prevent a backsliding in the use of statins for primary prevention”. For the study, Mortensen and colleagues compared the clinical performance of the 2021 ESC guidelines with those of the American College of Cardiology (ACC)/American Heart Association (AHA), UK – National Institute for Health and Care Excellence (NICE) and European 2019 guidelines in a contemporary European cohort of 66,909 apparently healthy people from the Copenhagen General Population Study.

During the 9-year follow-up, a range of 2962 to 4277 nonfatal and fatal cardiovascular events were observed. The results showed that although the ESC guidelines introduced a new improved risk model, known as SCORE2, the updated age-specific guidelines significantly reduced eligibility for a Class I recommendation for treatment. by statin to only 4% of people aged 40 to 69, and less than 1% of women. This is in stark contrast to previous EU guidelines from 2019 as well as current guidelines from UK-NICE and US-ACC/AHA which provide Class I/Strong recommendations to 20%, 26% and 34% of individuals , respectively, with better clinical outcomes. performance in both men and women, report the authors.

Even when statins are clearly indicated, it can be difficult to get patients to take them. Results from more than 600,000 commercially insured Americans with established atherosclerotic cardiovascular disease (ASCVD) showed:

  • Only 1 in 5 patients (22.5%) were taking a high-intensity statin

  • 27.6% were taking a low- or moderate-intensity statin

  • Half (49.9%) were not taking any statins.

Women were 30% less likely than men to receive a statin (OR, 0.70). A high Charlson Comorbidity Index score (OR, 0.72) and peripheral arterial disease (OR, 0.55) also reduced the odds of being prescribed a statin. Among statin users, middle-aged (OR, 0.83) and older (OR, 0.44) patients were less likely to take a high-intensity statin, as were women (OR, 0.68 ) and patients with peripheral arterial disease (OR, 0.43). However, seeing a cardiologist in the previous 12 months increased the likelihood of a patient taking a high-intensity statin (OR, 1.21), as did using other low-density lipoprotein cholesterol-lowering drugs (LDL) (OR, 1.44).

Patients taking statins may experience another benefit: a lower risk of hospitalization from COVID-19. An analysis of data from more than 2 million people who use statins found a 16% lower risk of hospitalization for COVID-19 compared to matched controls (adjusted hazard ratios, 0.84). The results were similar for in-hospital deaths associated with COVID-19.

From controversies over guidelines to potential preventative effects in NAFLD and COVID-19, recent news on statins has generated a lot of interest. As was the case last summer, when similar research garnered increased attention, drugs are once again the hottest clinical topic of the week.

Learn more about lipid-lowering agents.

Jessica C. Bell