‘Urgent need’ to increase statin use in low- and middle-income countries
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Statins remain widely underused across most low- and middle-income countries, with about one in 10 eligible people using statins for primary prevention and about one in five eligible people using them for secondary prevention.
A WHO target is that at least 50% of eligible people use statins for the prevention of CVD, yet among low- and middle-income countries, no region, income group or single country achieved the target of statin use for both primary and secondary prevention of CVD, David Flood, MD, MSc, of the division of hospital medicine at the University of Michigan, Sebastian Vollmer, MD, of the department of economics and Centre for Modern Indian Studies at the University of Göttingen, Germany, and colleagues wrote in The Lancet Global Health. Statin use was lower in less wealthy countries, in the African region and among traditionally marginalized groups such as those with less education or living in rural settings.
“There is an urgent need to scale up statin use in low- and middle-income countries,” Flood and Vollmer told Healio. “Policies and programs that facilitate implementation of statins into primary health systems in these settings should be investigated for the future.”
Assessing survey data
In a cross-sectional study, the researchers analyzed pooled, individual-level data from nationally representative health surveys conducted in 41 low- and middle-income countries from 2013 to 2019 (n = 116,449; 50% men). Survey respondents were aged 40 to 69 years.
“We prioritized WHO Stepwise Approach to Surveillance (STEPS) surveys because these are WHO’s recommended method for population monitoring of noncommunicable disease targets,” the researchers wrote. “For countries in which no STEPS survey was available, a systematic search was done to identify other surveys.”
Primary outcomes were the proportion of eligible individuals self-reporting use of statins for the primary and secondary prevention of CVD. Eligibility for statin therapy for primary prevention was defined as people with a history of diagnosed diabetes or a 10-year CVD risk of at least 20%. Eligibility for statin therapy for secondary prevention was defined as people with a history of self-reported CVD. At the country level, researchers estimated statin use by per-capita health spending, per-capita income, burden of CVD and commitment to noncommunicable disease policy. Countries were weighted in proportion to their population size in pooled analyses.
Within the cohort, 7.9% of the population-weighted sample reported a history of CVD.
Among those without history of CVD, 9.7% of the population-weighted sample were eligible for a statin for primary prevention of CVD.
Across countries, statin use was 8% (95% CI, 6.9-9.3) for primary prevention and 21.9% (95% CI, 20-24) for secondary prevention. No region or income group met WHO targets for statin use.
Statin use was less common in countries with lower health spending. At the individual level, researchers observed higher statin use for primary prevention among women (RR = 1.83; 95% CI, 1.22-2.76), as well as for adults aged 60 to 69 years (RR = 1.86; 95% CI, 1.04-3.33) and those with more education (RR = 1.61; 95% CI, 1.09-2.37). For secondary prevention, statin use was more common among adults aged 50 to 59 years (RR = 1.71; 95% CI, 1.35-2.18) and adults aged 60 to 69 years (RR = 2.09; 95% CI, 1.65-2.65), those with more education (RR = 1.28; 95% CI, 0.97-1.69) and those living in urban areas (RR for rural residence vs. urban = 0.82; 95% CI, 0.66-1).
Statin use ‘far too low’
“Our findings call for placing greater attention on integrated CVD management including scaling up of statin therapy in low- and middle-income countries,” Flood and Vollmer told Healio. “Despite being widely recommended in clinical practice guidelines and having been added to the WHO Essential Medicine List in 2007, use of statins is far too low. Our previous work has demonstrated that about three-quarters of people with diagnosed hypertension take antihypertensive medications and 85% of people with diagnosed diabetes take glucose-lowering medications. Given the disproportionate burden of CVD in low- and middle-income countries and the strong clinical evidence supporting statin therapy, our findings emphasize the urgent need to scale up statin use even relative to other medicines to prevent and control noncommunicable diseases.”
The researchers said barriers to increasing statin uptake generally and in underserved populations more specifically need to be identified and overcome.
For more information:
David Flood, MD, MSc, can be reached at dcflood@umich.edu; Twitter: @davidcflood.
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