title: Therapeutic practice patterns related to statin potency and ezetimibe/simvastatin combination therapies in lowering LDL-C in patients with high-risk cardiovascular disease.
abstract: BACKGROUND
  Statin combination therapy and statin uptitration have been shown to be efficacious in low-density lipoprotein cholesterol (LDL-C) lowering and are recommended for patients with high-risk coronary heart disease (CHD) who do not reach guideline-endorsed LDL-C goals on statin monotherapy.
  
  
  OBJECTIVE
  This analysis evaluated treatment practice patterns and LDL-C lowering for patients with CHD/CHD risk equivalent on statin monotherapy in a real-world practice setting in the United States.
  
  
  METHODS
  In this retrospective, observational study, patients with CHD/CHD risk equivalent on statin therapy were identified during 2004 to 2008 in a US managed care database. Prescribing patterns and effect of switching from statin monotherapy to combination ezetimibe/simvastatin therapy vs uptitration to higher statin dose/potency level and no change from initial statin potency on LDL-C lowering were assessed. Percentage of change from baseline in LDL-C levels and odds ratios for LDL-C goal attainment were estimated with analyses of covariance and logistic regression.
  
  
  RESULTS
  Of 27,919 eligible patients on statin therapy, 2671 (9.6%) switched to ezetimibe/simvastatin therapy, 11,035 (39.5%) uptitrated statins, and 14,213 (50.9%) remained on the same statin monotherapy. LDL-C reduction from baseline and attainment of LDL-C <100 and <70 mg/dL were substantially greater for patients who switched to ezetimibe/simvastatin therapy (-24.0%, 81.2%, and 35.2%, respectively) than for patients who titrated (-9.6%, 68.0%, and 18.4%, respectively) or remained on initial statin therapy (4.9%, 72.2%, and 23.7%, respectively). The odds ratios for attainment of LDL-C <100 and <70 mg/dL were also higher for patients who switched than for patients who uptitrated and had no therapy change than for patients who titrated vs no therapy change. Similarly, among a subgroup of patients not at LDL-C <100 mg/dL on baseline therapy, attainment of LDL-C <100 and <70 mg/dL was greater for patients who switched than for statin uptitration vs no change, as well as for patients who uptritrated statins vs no therapy change.
  
  
  CONCLUSIONS
  In this study, LDL-C lowering and goal attainment rates improved substantially for patients with high-risk CHD on statin monotherapy who switched to combination ezetimibe/statin or uptitrated their statin therapies; however, approximately one-third of these patients still did not attain the optional recommended LDL-C goal of <70 mg/dL. Moreover, these higher efficacy lipid-lowering therapies were infrequently prescribed, indicating the need for further assessment of barriers to LDL-C goal attainment in actual practice settings.
authors: CGH Medical Center, 101 East Miller Road, Sterling, IL 61081, USA; College of Medicine, University of Illinois, Peoria, IL, USA. Electronic address: Peter.Toth@cghmc.com.
authors: Peter P
authors: PP
authors: Toth
authors: Brigham and Women's Hospital, Boston, MA, USA.
authors: Joanne M
authors: JM
authors: Foody
authors: Merck & Co, Inc, Whitehouse Station, NJ, USA.
authors: Joanne E
authors: JE
authors: Tomassini
authors: Merck & Co, Inc, Whitehouse Station, NJ, USA.
authors: Shiva G
authors: SG
authors: Sajjan
authors: Merck & Co, Inc, Whitehouse Station, NJ, USA.
authors: Dena R
authors: DR
authors: Ramey
authors: Merck & Co, Inc, Whitehouse Station, NJ, USA.
authors: David R
authors: DR
authors: Neff
authors: Merck & Co, Inc, Whitehouse Station, NJ, USA.
authors: Andrew M
authors: AM
authors: Tershakovec
authors: Merck & Co, Inc, Whitehouse Station, NJ, USA.
authors: X Henry
authors: XH
authors: Hu
authors: Merck & Co, Inc, Whitehouse Station, NJ, USA.
authors: Kaan
authors: K
authors: Tunceli
mesh_terms: D001384:Azetidines / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000097:blood* / Q000188:drug therapy*; D008078:Cholesterol, LDL / Q000097:blood*; D004338:Drug Combinations; D000069499:Ezetimibe, Simvastatin Drug Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010818:Practice Patterns, Physicians'; D019821:Simvastatin / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D001384:Azetidines; D008078:Cholesterol, LDL; D004338:Drug Combinations; D000069499:Ezetimibe, Simvastatin Drug Combination; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D019821:Simvastatin
keywords: Ezetimibe; Goal attainment; Low-density lipoprotein cholesterol; Statins; Switch