Incremental statin dose-related LDL-C lowering effect in Asians lower than reported

In Asian patients with dyslipidemia, statin intensity titration exerts favourable effects on low-density lipoprotein cholesterol (LDL-C) levels and goal attainment rates, although the magnitude appears to be lower than reports from clinical trials, according to a study.

“The LDL-C lowering effect when initiating low-, moderate-, and high-intensity statin was … 21.6 percent, 28.9 percent, and 25.2 percent, respectively. In contrast, a systemic review published by the US Agency for Healthcare Research and Quality had quoted a <30 percent, 30–50 percent, and >50-percent reduction across the three intensity bands,” the investigators said. [J Am Coll Cardiol 2019;73:3168–3209]

“One possible reason for this discrepancy is due to suboptimal medication adherence among patients in the real-world [setting]. This is supported by findings from another real-world study on LDL-lowering effect by Koren [and colleagues], which saw a 35.3-percent LDL-C reduction on starting high-intensity atorvastatin,” they noted. [BMJ Open 2019;9:e024937; Am J Med 2005;118:16-21]

The current study used real-world data from a cohort of 11,499 multiethnic Asian adults with dyslipidemia who sought primary care from a clinic in Singapore. Over a 5-year period, the cohort contributed to a total of 266,762 visits, and there were 1,561 patients on statin who underwent intensity titration.

As pointed out earlier, the LDL-C lowering effect of statins in the cohort was lower than results from clinical trials (21–25 percent vs 30–63 percent). LDL-C levels decreased by 12.4−28.9 percent after up-titration, rose by 13.2–24.6 percent after down-titration, and increased by 18.1–32.1 percent following discontinuation. [Lipids Health Dis 2021;20:2]

The number of patients who achieved their LDL-C goals ranged from 26.5 percent to 47.1 percent when statin intensity was up-titrated. Furthermore, multivariate logistic regression models indicated a strong association between statin intensity up-titration and LDL-C goal attainment (odds ratios, 1.3–6.1).

Clearly, up-titration is more effective in lowering the LDL-C value than maintaining the dose, the investigators said. “There was at least 12.4-percent LDL reduction for statin up-titration compared to a relatively modest 1.1-percent reduction for no-titration. This is to be expected as constant dose of statin is typically used to maintain LDL-C rather than lower it.

“These results should be taken into consideration and provide further insight to clinicians when making statin adjustment recommendations in order to achieve LDL-C targets in clinical practice, particularly for Asian populations,” they said.

The investigators also believe that the data may inform the development of a patient decision support tool to help facilitate shared decision-making in statin therapy. “This tool is envisioned to assist patients and clinicians when selecting, initiating, and adjusting statin therapy, so as to achieve best possible clinical outcomes and minimal adverse effects.”