Literally billions of prescriptions for medications are written each year in the United States. Lipid modulators are the most frequently prescribed class of drugs.
Lipid modulators are drugs requiring blood tests to see how they are working. As a result, a considerable amount of clinical time is spent chasing numbers as we treat to target. Dose escalations are a frequent, almost reflexive, response to LDLs that are not at goal. Such decisions are made easier because there is commonly equivalent pricing on different doses (that is, 80 mg of atorvastatin is the same cost as 20 mg of atorvastatin).
Many of these decisions are made sight unseen and relayed through clinical support staff. But maybe those decisions shouldn’t be made quite so fast.
Pittman and colleagues published an analysis of the relationship between statin nonadherence and treatment intensification (Am. J. Cardiol. 2012;110:1459-63). Investigators conducted a retrospective analysis using an integrated pharmacy and medical claims database including more than 126,000 patients. Claims were analyzed to determine medication nonadherence, which was defined as the proportion of statin-covered days totaling less than 80%. Nonadherence was then related to statin dose escalations over a 360-day period of follow-up.
Disturbingly, but perhaps not completely surprisingly, 44% of the 11,361 patients who received an increased dose were nonadherent to the medication. Patients who were nonadherent to statins were 30% more likely to have treatment escalation than nonadherent patients.
Many of us are, in fact, conducting "adherence conversations" with our patients much of the time. But not all of us are having these conversations all of the time. Although a significant barrier may be lack of adequate time, one could argue that the more significant barriers are the lack of clinical tools to assess adherence and not knowing what defines true "nonadherence" for statins. We are perhaps not certain what the least amount of a cholesterol-lowering agent is that somebody needs to take and have it still be effective at reaching an individual’s goal LDL.
In the absence of this knowledge, we could consider implementing an "80% rule" based upon the cutoff selected in this article.
If we or our clinical staff receive a "no" to the question, "Did you use the medication more than 80% of the time?" we could address adherence issues, maintain the current dose, and recheck the LDL in 3 months. At the very least, we could avoid needing to fill out another prescription.
Dr. Ebbert is professor of medicine and primary care clinician at the Mayo Clinic in Rochester, Minn. He reports having no conflicts of interest. The opinions expressed are solely those of the author.