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Inefficacia del trattamento ipolipemizzante: bassa aderenza o sottoprescrizione?

I pazienti non ricavano il massimo beneficio atteso dall'uso di agenti ipolipemizzanti per una serie di motivi: i fattori a livello medico includono una conoscenza limitata delle evidenze e un rischio reale o percepito di effetti avversi, oltre alla riluttanza a prescrivere la terapia con statine ad alta intensità, mentre i fattori a livello di paziente includono un’assunzione dei farmaci non coerente con le indicazioni del medico (bassa aderenza) o la sospensione del farmaco (bassa persistenza). Questo studio ha valutato l'associazione della combinazione di due fattori, aderenza e intensità del trattamento, con la riduzione del colesterolo LDL e con gli outcome cardiovascolari in pazienti ad alto rischio di eventi CV che iniziavano una terapia ipolipemizzante. I pazienti aderenti che ricevevano una terapia ad alta intensità presentavano un rischio inferiore del 40% di un evento cardiovascolare, mentre per i pazienti non aderenti sottoposti a terapia a bassa intensità la riduzione era del 5%.

Association of a Combined Measure of Adherence and Treatment Intensity With Cardiovascular Outcomes in Patients With Atherosclerosis or Other Cardiovascular Risk Factors Treated With Statins and/or Ezetimibe

Khunti K, Danese MD, Kutikova L, Catterick D, Sorio-Vilela F, Gleeson M, Kondapally Seshasai SR, Brownrigg J, Ray KK

JAMA Netw Open 2018;1:e185554

Importance: Both adherence and treatment intensity can alter the effectiveness of lipid-lowering therapy in routine clinical practice.
Objective: To evaluate the association of adherence and treatment intensity with cardiovascular outcomes in patients with documented cardiovascular disease (CVD), type 2 diabetes without CVD or chronic kidney disease (CKD), and CKD without CVD.
Design, Setting, and Participants: Retrospective cohort study using the Clinical Practice Research Datalink from January 2010 through February 2016. United Kingdom primary care was the setting. Participants were newly treated patients who received their first statin and/or ezetimibe prescription between January 1, 2010, and December 31, 2013, plus an additional prescription for statins and/or ezetimibe during the following year.
Exposures: Adherence was assessed annually using the proportion of days covered, with adherent defined as a proportion of days covered of 80% or higher. Treatment intensity was classified according to guidelines based on the expected percentage of low-density lipoprotein cholesterol (LDL-C) reduction as low (<30% reduction), moderate (30% to <50% reduction), or high (≥50% reduction). Adherence and treatment intensity were multiplied to create a combined measure, reflecting treatment intensity after accounting for adherence.
Main Outcomes and Measures: Composite end point of cardiovascular death or hospitalization for myocardial infarction, unstable angina, ischemic stroke, heart failure, or revascularization. Hazard ratios (HRs) were estimated against patients not treated for 1 year or longer.
Results: Among a total of 29 797 newly treated patients, there were 16 701, 12 422, and 674 patients with documented CVD, type 2 diabetes without CVD or CKD, and CKD without CVD, respectively; mean (SD) ages were 68.3 (13.2), 59.3 (12.4), and 67.3 (15.1) years, and male proportions were 60.6%, 55.0%, and 47.0%. In the documented CVD cohort, patients receiving high-intensity therapy were more likely to be adherent over time (84.1% in year 1 and 72.3% in year 6) than patients receiving low-intensity therapy (57.4% in year 1 and 48.4% in year 6). Using a combined measure of adherence and treatment intensity, a graded association was observed with both LDL-C reduction and CVD outcomes: each 10% increase in the combined measure was associated with a 10% lower risk (HR, 0.90; 95% CI, 0.86-0.94). Adherent patients receiving a high-intensity regimen had the lowest risk (HR, 0.60; 95% CI, 0.54-0.68) vs patients untreated for 1 year or longer. Findings in the other 2 cohorts were similar.
Conclusions and Relevance: Results of this study demonstrate that the lowest cardiovascular risk was observed among adherent patients receiving high-intensity therapy, and the highest cardiovascular risk was observed among nonadherent patients receiving low-intensity therapy. Strategies that improve adherence and greater use of intensive therapies could substantially improve cardiovascular risk.

JAMA Netw Open 2018;1:e185554