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Australian Journal of Pharmacy : April 2005
Hear more about statins T as there is such a big government invest- ment in this area. ‘There is enormous merit in having sys- tems in place for pharmacies to track patient compliance with chronic thera- pies and this can only lead to better health outcomes. Patients need to be made aware that any drug withdrawal can have harmful consequences. ‘With therapies for diabetes, where there is multiple doses each day, compli- ance decreases further. Added to this is multiple medication therapy and skipped doses and [as a result] it becomes even more dangerous. ‘Even with Lipitor and the other statin therapies coming on board, there could be a simple index that enables pharmacy to track and indicate how a patient is per- forming in the compliance area. ‘This would be very simple to monitor and would be welcomed by doctors and patients alike,’ Mr Sclavos concluded. Reasons for compliance Brisbane cardiologist, Associate Professor David Colquhoun, said compliance can be a problem with any therapy. ‘People who tend to be compliant have a good reason to comply, such as preven- tion of coronary heart disease. Compli- ance is much better than it used to be a few years ago. Even depressed patients have improved compliance—up to 90 per cent compliance [with statin therapy].’ However, Dr Colquhoun noted, asymptomatic and obese individuals had a greater tendency to be non-compliant. Compliance to statin therapy was no less than any other therapy for an asympto- matic disorder, he said. ‘There is no doubt compliance can be a problem, but it is usually related to physi- cian, health provider or patient factors. Clearly, it is not just a patient’s fault— patients need very good reasons to keep swallowing tablets. It is over to us to help and pharmacy can play a pivotal role.’ According to Dr Colquhoun, when it comes to the management of cholesterol, there is no doubt that statin therapy had made a huge difference to heart disease and survival rates. ‘If you treat 20 patients with a statin for five years, you prevent one cardiovascu- lar event on average. In other words, one less heart attack, one less stroke, or one less death.’ In patients where there are multiple factors, such as diabetes and hyperten- sion, the prevention rates are even higher. ‘Treat five patients for five years and you can prevent one CVD event. If a patient has had a heart attack, even with cholesterol as low as 3.4mmol/L, if the HDL cholesterol is less than one, then this group also benefits from the statins.’ ‘Statins are as beneficial to patients as penicillin was to the health of the com- munity at the time. Statins are that signif- icant a breakthrough. These drugs lower cholesterol and lead to stabilisation of the plaque, reducing the progression of ath- erosclerosis and, more importantly, cut- ting heart attack and stroke rates.’ Dr Colquhoun said there was also new evidence that supported better patient outcomes when high-risk patients were given more aggressive cholesterol lower- ing therapy instead of standard-dose treatment. ‘There appears to be less progression of cardiovascular disease in patients taking optimum levels of statin therapy. Patients with higher LDL, above 3 mmol/L to start with at baseline had better outcomes. So, for heart patients at very high risk with known coronary heart disease and dia- betes, or those patients with known coro- nary disease and multiple risk factors, the optional target is to get LDL below 1.9 mmol/L,’ Dr Colquhoun said. What memory loss? According to Associate Professor Len Kritharides, a review of 60 reported cases of cognitive impairment found that in half of all patients, impairment occurred within two months of taking statins. Dr Kritharides, who is head of cardiol- ogy at Sydney’s Concord Hospital, said although the evidence associating statins with memory loss was not conclusive, the data suggested it could occur in rare cases. ‘Some patients do experience side effects from statins, such as muscle pain or HE Pharmaceutical society of Australia (PSA) is holding evening lectures in Sydney and Adelaide for pharmacists interested in getting an update on statin therapy. In New South Wales the PSA has organised ‘Trends in Lipid Management’ on the evenings of 12 and 13 April, presented by Associate Professor Leon Simons, head of the Cholesterol Clinic at Sydney’s St Vincent’s Hospital. In South Australia, the PSA will hold Pathophysiology Round Six on 3 August at the Adelaide office with consultant cardiologist Dr Ian Hamilton-Craig. sleep disturbance, but the vast majority have no problems. ‘My advice to patients is that there have been no systematic reports of memory loss from randomised, controlled studies of thousands of patients taking cholesterol- lowering medicines. Statins unequivo- cally reduce the risk of heart attacks and stroke, and do save lives. Consequently, the decision to stop statins for a potential side effect such as memory loss has to be weighed carefully against the potential loss of benefit. He said recent research indicated that statins may have a benefit in other inflam- matory conditions like arthritis or multi- ple sclerosis. Researchers have looked at the demen- tia issue in a couple of major statin stud- ies and the overall result has been nil— ‘neither beneficial or harmful.’ Larger studies are currently in progress to address this issue. As for prescribing statins to those at risk of heart disease, such as diabetics, when so called “normal” cholesterol levels are present, Dr Kritharides said it was neces- sary to conform to PBS guidelines. ‘These guidelines currently specify plasma cholesterol levels above which patients are eligible to receive subsidised cholesterol-lowering statin drugs. It will be interesting to see how PBS guidelines evolve as data accumulates. Certainly once patients have commenced cholesterol-low- THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 APRIL 2005 ? 249