As our practice partners increasingly shift to value-based payment models that rightly focus on delivering optimal outcomes, one of the many things they are measured on is the quality performance measure of statin use. This is of particular importance in treating the growing U.S. epidemic of diabetes, which the CDC reported in 2020 affects the health of 10.5% of the U.S. population overall…and almost three times that for persons 65 and up.
Guidelines recommend that many diabetes patients take a statin to reduce the risk of cardiovascular disease (CV) and death. However, about half of eligible patients aren’t on a statin at all, or are taking too low a dose. Especially since the incidence of diabetes increases significantly as patients age — 17.5% of patients ages 45 to 64 and 26.8% of those 65 and older, according to CDC-compiled data — RxLive clinical pharmacists discuss statin use with most type 1 or type 2 patients, particularly those aged 40 to 75. This aligns with the evidence presented and recommendations of the American Association of Family Physicians (AAFP) and the U.S. Preventive Services Task Force (USPSTF).
Statins and COVID-19 hospital deaths
Interestingly, a recently released study showed that people who took statins to lower cholesterol were approximately 50% less likely to die if hospitalized for COVID-19, according to a study by cardiologists at Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian Hospital found. The study, based on outcomes of 2,626 inpatients in the first 18 weeks of the pandemic, will be the foundation for further research due to the high rates of hyperinflammation and clotting of COVID-19-hospitalizated patients and the significant impact of statins on those symptoms.
Drug interactions; some statins are tricky
There are some trends in why some patients we’ve consulted with haven’t been on a statin, or the optimum dose. Many physicians are hesitant to prescribe statins because of the “statin-intolerance” of some patients, or because some patients are already on a rather heavy medication regimen.
However, over 70% of these statin-intolerant patients can take a statin with patience and persistence in prescribing and monitoring. We just strongly recommend that physicians double check to help ensure you’re avoiding significant statin drug interactions. Below I’ve called out a few confusing statin interactions to be aware of.
We all know to watch for the more-problematic statins — simvastatin, lovastatin or atorvastatin — since they’re metabolized by CYP3A4 the most; however, there are some interactions that are a bit trickier.
Not all azole antifungals are a problem. Fluconazole is less risky. It’s a moderate 3A4 inhibitor, while most others are strong inhibitors. We recommend not to be too concerned about single-dose fluconazole. However, patients should be advised to report muscle symptoms when longer courses of fluconazole are used with simvastatin, lovastatin or atorvastatin.
For most other azoles (itraconazole, etc.), we suggest holding simvastatin or lovastatin during the antifungal course and for about three days after. Also, we recommend caution with atorvastatin depending on the azole.
Not all macrolides are a problem and it’s usually ok to use azithromycin, but we recommend avoidance of other macrolides with lovastatin or simvastatin.
Fenofibrate isn’t as risky as gemfibrozil, but we recommend that patients who are on fenofibrate plus any statin to report muscle problems. There actually isn’t any good evidence that adding a fibrate to a statin improves CV outcomes, so we use this as a reason to re-evaluate fibrate use.
Grapefruit juice doesn’t need to be avoided with all statins, but patients on simvastatin or lovastatin should avoid it, while patients on atorvastatin should drink fewer than about four cups a day. If a patient just loves grapefruit, we suggest switching to a different statin. (This doesn’t apply to grapefruit-flavored drinks that have very little juice.)
Dosing
It’s also important to check that the statin dose is appropriate. For most diabetic patients with CV disease, LDL-C level ≥ 190 mg/dL or additional risk factors, we typically recommend a high-intensity statin (atorvastatin 80 mg/day, etc.) For diabetes patients without CV risks or an LDL-C level of ≥ 70, we suggest a moderate-intensity statin (atorvastatin 20 mg/day, etc.)
When choosing a statin dose, expected LDL reduction isn’t the only factor to consider. Dosage adjustments may be needed based on renal function, race or drug interactions.
If one of our clinical pharmacists recommend a statin to a patient, we also explain the benefit of sticking with it and their diabetes meds to achieve the maximum results achievable.
Starting the conversation
No one really wants to add another medication to their regimen. Thus, we believe in opening the door to discussions about statins — actually, opening all investigatory conversations with patients that may conclude with recommended regimen changes, plus or minus — with non-threatening, open-ended questions.
For example, in this instance we may ask “May I ask if you’ve been prescribed a statin medication before? What was your experience with that medication? Have any of your providers talked with you about the benefits of adding a statin to your routine? May I share that information with you now? Would you be open to revisiting that conversation?”
In this way, our consulting pharmacists can effectively assess the patient’s past experience and can help determine what areas of resistance we may need to address, rather than just telling a patient that he or she should be taking a statin. We firmly believe that part of our role as a medication consultant is to educate patients and involve them in their own health, which is not only the right thing to do, but most likely to achieve and maintain adherence.
Of course, we make recommendations that are sent back to a patient’s physician for approval and follow-up. We are an extension of their team and a medication change is ultimately the prescriber’s decision. But by us opening the door to a discussion about statins as part of a medication review, it can lead to a change that can improve a patient’s quality (and hopefully length) of life while helping their physician practice meet one of many important quality performance benchmarks.
Resources
VA Analysis Finds Significant Benefit for Statins in Veterans 75 and Older. U.S. Medicine, 2020
U.S. Preventive Services Task Force (multiple resources)
