Younger Adults With Severe Dyslipidemia Less Likely to Be Prescribed Statins

Just two-thirds of US adults with severe dyslipidemia are taking a statin medication to lower LDL cholesterol levels, and for younger individuals, specifically those in their 30s and 40s with severe dyslipidemia, statin prescription rates are even lower, a new analysis shows.

Among patients younger than 40 years of age, for example, less than 45% with LDL cholesterol levels 190 mg/dL or greater are prescribed a statin.

“We see these differences in prescription rates and for the group that seems to have a treatment gap, you could argue this is the group that’s most important [as] it’s a disease that’s genetic and can lead to premature heart disease,” said senior investigator David Zidar, MD (University Hospitals Cleveland Medical Center, OH). “So really, defining what is driving the treatment gap and trying to come up with strategies that might better ensure these patients get treated and followed might have a demonstrable impact on outcomes.”

According to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) clinical guidelines, statin therapy is recommended for individuals 21 years and older with LDL cholesterol levels ≥ 190 mg/dL (an estimation of 10-year risk is not required). LDL cholesterol reduction with a statin is recommended in these individuals given their high lifetime risk of atherosclerotic cardiovascular disease (ASCVD).

To TCTMD, Zidar noted that population-health studies have shown that, now that statins are generic and these high-risk patients have a clear indication for statin therapy, closing the treatment gap can lead to cost savings in the healthcare system.

“It’s one of those few areas in medicine where all the potential stakeholders are more aligned than in other areas where we get into problems of cost,” he said. “This is a rare area where we have really good data, good surrogates, and we can identify patients and treat them with a generic medicine and have some trust we’re improving their health outcomes without driving up costs.”

Clear Indication for Statin Therapy 

In their analysis, published January 4, 2017, in JAMA Cardiology, the researchers identified 2,884,260 patients who underwent lipid testing at 360 medical centers in all 50 states. They then identified individuals with one or more indications for statin therapy: severe dyslipidemia (LDL cholesterol level 190 mg/dL or greater), diabetes plus LDL cholesterol 70 mg/dL or greater, and a diagnosis of ASCVD. They did not include patients with a 10-year cardiovascular risk of 7.5% or higher, a controversial group of patients who would also be eligible for treatment based on the 2013 ACC/AHA guidelines.

Of the nearly 3 million patients, 109,980 (3.8%) had an LDL cholesterol level 190 mg/dL or greater. Of those with severe dyslipidemia alone, 66% were prescribed a statin. Similar prescription rates were observed for those with diabetes but without severe dyslipidemia (69%) and those with a diagnosis of ASCVD alone (68%). 

In individuals aged 40 to 75 years, statin prescription rates increased if the patient had an additional indication for treatment. For example, among those with LDL cholesterol levels ≥ 190 mg/dL and diabetes or ASCVD, 84% were prescribed a statin. For those with all three indications—ASCVD, diabetes, and severe dyslipidemia—93% were prescribed statin therapy.

The use of statins varied dramatically by age, however. For men and women in their 30s, 40s, and 50s with severe dyslipidemia, statin prescription rates were 32%, 47%, and 61%, respectively. On multivariate regression analysis, age was the most important predictor of statin prescription, while other predictors included male sex, nonwhite race, and self-pay status.

Less Aggressive Treatment

To TCTMD, Zidar said they were surprised by the findings, noting they would have expected younger patients to be better treated given that they’re relatively “uncomplicated, straightforward.” In older patients, there is often a range of comorbidities to treat, and physicians might “gloss over” an abnormal laboratory value, he added.

Lead researcher Sadeer Al-Kindi, MD (University Hospitals Cleveland Medical Center), said patients with LDL cholesterol levels ≥ 190 mg/dL would definitely be flagged as high risk by cardiologists and are clearly indicated for treatment based on the latest guidelines. However, primary care physicians might not necessarily be as up to date on all the recommendations for primary-prevention treatment. 

As to why younger patients might not be treated, Zidar noted that high cholesterol is frequently associated with obesity, lack of exercise, and poor diets. Initial strategies in younger patients with elevated cholesterol levels frequently include advice to modify their diet and get active, but for patients with severe dyslipidemia, controlling LDL levels in a meaningful way with lifestyle is extremely challenging, said Zidar. It also misses the point that some of these patients might have familial hypercholesterolemia, a condition where elevated LDL levels are driven by genes, he said.

“There might also be the false sense of security that these patients are young and we have a couple of years to work on this,” said Zidar, speculating on possible reasons for their results. “From a physician standpoint, there might be some degree of not wanting to necessarily treat someone for decades with a cholesterol medicine.”

Zidar noted that younger patients can be “difficult to corral” into the healthcare system and might be infrequent visitors to the family physician. As a result, they might be lost to follow-up after an initial lipid screening.

For individuals with LDL cholesterol levels of 190 mg/dL or greater, the ACC/AHA guidelines recommend physicians prescribe a high-intensity statin to achieve at least a 50% reduction in LDL levels. Despite the use of maximal therapy, it is recognized that many of these individuals with severe elevations in LDL may require additional cholesterol-lowering medications, such as ezetimibe (Zetia, Merck/Schering-Plough) or the newer PCSK9 inhibitors evolocumab (Repatha, Amgen) or alirocumab (Praluent, Sanofi/Regeneron), to achieve acceptable LDL cholesterol levels.