Despite recommendations, statin use ‘not ubiquitous’ in CKD with ASCVD
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Overall statin use among adults with chronic kidney disease is high, yet there have been only modest increases in the use of high‐intensity statins, ezetimibe and PCSK9 inhibitors, data from a prospective 2‐year study show.
Both the 2013 Kidney Disease: Improving Global Outcomes (KDIGO) and 2018 American College of Cardiology/American Heart Association cholesterol guidelines recommend at least statin therapy for adults with non‐dialysis-dependent chronic kidney disease (CKD) and atherosclerotic CVD, as CKD is a major risk factor for disease progression, Robert S. Rosenson, MD, director of metabolism and lipids for the Mount Sinai Health System and professor of medicine in cardiology at the Icahn School of Medicine at Mount Sinai, and colleagues wrote. The ACC/AHA guidelines recommend the use of high‐intensity statins with the addition of ezetimibe and/or a PCSK9 inhibitor specifically to achieve a cardioprotective LDL goal of 70 mg/dL or lower.
“Based on these guidelines, all patients with CKD in our study should be receiving statin therapy, ideally of high intensity, and many should also be on ezetimibe and/or PCSK9 inhibition,” Rosenson and colleagues wrote. “However, we found that statin use is not ubiquitous, and rates of high‐intensity statin and ezetimibe use remain low in this patient population.”
Rosenson and colleagues analyzed changes in use of lipid-lowering therapies over 2 years in 3,304 patients with ASCVD and CKD in the observational GOULD study. As Healio previously reported, in GOULD, fewer than 20% of patients with ASCVD had their lipid-lowering therapy intensified and approximately 30% achieved an LDL goal of less than 70 mg/dL. Enrolled patients were divided into three cohorts: currently receiving a PCSK9 inhibitor (n = 554), LDL at least 100 mg/dL and not on PCSK9 inhibition (n = 1,801), and LDL between 70 mg/dL and 99 mg/dL and not on PCSK9 inhibition (n = 2,651). Patients with available data on baseline estimated glomerular filtration rate (eGFR) were categorized by kidney function. Researchers collected baseline data and prospective data collection was completed through chart review every 6 months for 2 years.
The findings were published in Clinical Cardiology.
Overall, the use of any statin remained relatively stable over 2 years, according to the researchers. For patients with stage 2 CKD, statin use was 84.8% at baseline and 83.4% at 2 years. Among patients with stage 3 CKD, statin use was 82.8% at baseline and 80.3% at 2 years. For those with stage 4 to 5 CKD, 87.5% of patients were using statins at baseline compared with 78.7% at 2 years.
Among patients with an eGFR of 60 mL/min/1.73 m2 or lower, 21.6% had an intensification of lipid-lowering therapy, whereas 10.4% had a de-escalation of lipid-lowering therapy and 61.6% had no change in their lipid-lowering therapy regimen over 2 years.
The use of statins plus ezetimibe increased from 2.9% to 4.9%; statin discontinuation at 2 years was higher among patients with a lower eGFR across all cohorts, according to the researchers.
“Despite ASCVD being a major cause of morbidity and mortality in patients with CKD, a majority of patients in this study did not achieve an atheroprotective LDL‐C goal of less than 70 mg/dL,” the researchers wrote. “This highlights a key opportunity to improve quality of care and outcomes in the CKD population.”
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