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High-dose statins potentially overused for some patients with diabetes
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Some patients with diabetes are being overtreated with high-dose statins, researchers from the University of Michigan Health System and the VA Ann Arbor Healthcare System suggest.
“We want patients to get the treatment they need to prevent heart attacks and cardiovascular issues, but we don’t want to expose them to additional treatment risks without strong evidence of the benefits,” Eve Kerr, MD, researcher and director of the Center for Clinical Management Research at the VA Ann Arbor Healthcare System and professor of internal medicine at the University of Michigan Medical School, said in a press release. “We need to move away from a one-size-fits-all performance measure that misses the point of providing appropriate treatment.”
Kerr and researchers utilized data from Veterans Affairs primary care patients aged 50 to 75 years (n=668,209).
They defined three conditions as successfully meeting what they describe as a “clinical action measure” in this patient population: 1) LDL <100 mg/dL; 2) taking a moderate-dose statin regardless of LDL level or measurement; or 3) receiving appropriate clinical action (starting, switching or intensifying statin therapy) if LDL is ≥100 mg/dL.
Of the patients included in the clinical action measure, 84.6% passed (67.2% with LDL <100 mg/dL; 13% with LDL ≥100 mg/dL) either on a moderate-dose statin (7.5%) or an appropriate clinical action (5.5%), in addition to 4.4% with no index LDL on at least a moderate-dose statin.
Kerr and colleagues determined that 13.7% were potentially overtreated when the entire cohort was considered. However, VA facilities with greater rates of meeting a threshold of an LDL <100 mg/dL led to higher rates of potential overtreatment (P<.001), they wrote.
Although approximately 85% of patients with diabetes aged 50 to 75 years are receiving adequate lipid management, the researchers conclude that many are still being overtreated with high-dose statins. Individualized care is encouraged in this patient population, and the researchers suggest the use of clinical action measures to enhance treatment.
Disclosure: Hofer and Kerr have received research grants. All other researchers report no relevant financial disclosures.
Perspective
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George Bakris, MD
The approach used at VA hospitals across the country has clearly resulted in one of the best control rates for CV risk factors. The message put out by guideline committees for BP goals is rather simple (ie, BP goal <140/90 mmHg) and use of one of three classes of drugs initially to achieve this goal is fine. However, physician inertia is a major problem with BP control since most Americans with hypertension require 2.1 antihypertensive medications at moderate doses. Conversely, lipid management has multiple goals focused on LDL <100 and <70 mg/dL. Moreover, trials like TNT push the concept that a maximum dose statin should be used so physician inertia is not a problem with statin dose. Plus, meta-analyses show a linear relationship between LDL level and risk for myocardial infarction. Many physicians do not read the details of trials; only the conclusion of the abstract and the brief message of many such studies do not include the inclusion criteria of the cohort studied. Thus, it is not surprising that higher doses that are not appropriate are used in many patients. What is more disturbing was in a system that rewards proper approaches to patients, 6% didn’t have cholesterol measured and patients not treated.
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