Initiating Statin Therapy

[Bitsy]

Hi all,

I hope this is okay to post this question on here - see poll.  It's a follow-up question to another thread I started. This is for a research project on reducing cardiovascular risk - educational purposes only; will not be submitted for publication in a professional journal. I've notice many providers/preceptors throughout my rotation practice differently. The poll is made to determine what factors providers are using in their MDM to initiate statins. 

I would love to see what your answers are.  If this is not appropriate for posting then please feel free to remove.  Your help is greatly appreciated!

 

 

[thinkertdm]

I usually just go with whatever drug company pen I'm using at that moment.  If I have two in my pocket, I go with the one that doesn't smear.

[MedicinePower]

"For pt in #1 stem, which would you decide to prescribe a statin?"

What does this question mean? It's a bit confusing. In general anyone with an LDL >190 gets a mid-intensity statin, and if they have anything else going on (HTN, DM, ASCVD ≥7.5) they get a high-intensity statin. I urge high-intensity Rosuvastatin as it's non-lipophillic (won't cause muscle aches) and recently went generic.

[DizzyJ]

3 hours ago, MedicinePower said:

"For pt in #1 stem, which would you decide to prescribe a statin?"

What does this question mean? It's a bit confusing. In general anyone with an LDL >190 gets a mid-intensity statin, and if they have anything else going on (HTN, DM, ASCVD ≥7.5) they get a high-intensity statin. I urge high-intensity Rosuvastatin as it's non-lipophillic (won't cause muscle aches) and recently went generic.

I think the lack of responses goes along with poorly written questions.  I would suggest a rewrite.  Patient A should be clearly defined as "have BP 140/80, LDL > 190, no h/o smoking, CV events or DM.  Then Patient B....well who is patient B?  From my interpretation Patient B is the same as Patient A, but with a strong family history of CVD.  This should be made more clear.  One could read Patient A, B, and C and expect them to perhaps have different variables.  They are all baseline Patient A and then adding a variable to their equation to become patient B and C.  It really isn't clear. 

And what is pt in #1 stem?  What is stem? 

[Febrifuge]

Family history is not a risk factor under the ACC guidelines. Neither is low socioeconomic status. Are you trying to study actual practice patterns, or how well people know and follow the evidence-based recommendations? 

[MCHAD]

I’m so confused by this question.  I have a  bachelors degree in physiology with a minor in chemistry and survived PA school and for the life of me I cannot figure out this question.

I did go to public school in Idaho growing up...maybe that’s where my deficiency comes from...

[Bitsy]

On 11/2/2017 at 0:04 AM, MedicinePower said:

"For pt in #1 stem, which would you decide to prescribe a statin?"

What does this question mean? It's a bit confusing. In general anyone with an LDL >190 gets a mid-intensity statin, and if they have anything else going on (HTN, DM, ASCVD ≥7.5) they get a high-intensity statin. I urge high-intensity Rosuvastatin as it's non-lipophillic (won't cause muscle aches) and recently went generic.

Sorry all - I realized after asking a few others in clinic that ... yes I suck at making survey questions. 

As for Medicine Power's question: Yes you're correct. Anyone with an LDL >190 would be indicated by ACC.  The question is throwing everyone off b/c current guidelines are indicating to use statins. However there are some discrepancies.  Some providers are hesitant on initiating statins based on some factors, even though it is indicated.  I'm using this survey to determine what those factors are.

[Bitsy]

On 11/2/2017 at 11:15 PM, MCHAD said:

I’m so confused by this question.  I have a  bachelors degree in physiology with a minor in chemistry and survived PA school and for the life of me I cannot figure out this question.

I did go to public school in Idaho growing up...maybe that’s where my deficiency comes from...

Nope MCHAD - it's me... I know it.  I'd re-edit this poll but I'm not sure how.  I don't use threads enough - probably should.  

On 11/2/2017 at 8:03 PM, Febrifuge said:

Family history is not a risk factor under the ACC guidelines. Neither is low socioeconomic status. Are you trying to study actual practice patterns, or how well people know and follow the evidence-based recommendations? 

Febrifuge - yes you're right... on both family history, low socioeconomic status and actual practice patterns.  This is not about how well people are following but what rationale real life clinician are using with these tools.  

[Bitsy]

My bad everyone. I edit the poll  as follows below, but I couldn't change what's listed above.  Thanks for clarifying with me.  I'm so engrossed in the research project that I didn't see how confusing it was.  

============================================================================

For the following questions, the patient has the profile:
BP 140/80, LDL > 190, no  h/o smoking, CV events or DM

1)    Under which of following conditions for your patient are you more likely to initiate statin therapy for:
           a)    no other risk factors
           b)    + strong family hx early CVD
           c)    + low socioeconomic status
           d)    A and B
           e)    B and C
            f)    All of the above
           g)    None
            h)    Only if symptomatic
2)    As the patient ages, at what point would you decide to prescribe a statin?  
            a)    Age 45 w/ ASCVD risk 4.7%
            b)    Age 55 w/ ASCVD risk 10.3% 
            c)    Age 65 w/ ASCVD risk 19.3%
            d)    B and C
            e)    None of the above
            f)    Only if symptomatic
 

[GetMeOuttaThisMess]

I understand that this is a research project but with the current statin guidelines the correct answer is pretty cut/dry.  Anybody with LDL >190 mm/dL gets a mod/high dose statin and stays on it indefinitely.  Same with CVD risk >7.5% over 10 years between ages 40 & 75.  Any other scenarios listed are patient's choice and low dose statin.  You also no longer have target LDL levels to shoot for.  This is why a statin is part of the new, upcoming "polypill" that we've been discussing for decades that includes a beta-blocker, ASA, and a benzo.  You might be able to substitute a CCB for the beta-blocker present day.

Maybe the question should've been "For the following patient profiles who do you put on a statin and at which dose?"

[Guest Paula]

Why would a drug company put a benzo into a polypill of a statin, beta blocker and an aspirin?

Answer: To reduce the anxiety induced by statinitis. 

[MedicinePower]

On 11/4/2017 at 10:39 AM, GetMeOuttaThisMess said:

This is why a statin is part of the new, upcoming "polypill" that we've been discussing for decades that includes a beta-blocker, ASA, and a benzo.  You might be able to substitute a CCB for the beta-blocker present day.

JNC8 removed beta blockers from first-line HTN therapy. It's appropriate for someone who has had an MI in order to allow for better coronary perfusion. First-line antihypertensives are either ACE-I/ARBs, CCBs, or thiazide diuretics alone or in combination (ACE-I + CCB).

Why would a "polypill" include a BZD? I can see one pill including Rosuvastatin + first-line antihypertensives + ASA but I can't understand the BZD.

[GetMeOuttaThisMess]

Never mind folks. It’s all old joke dating back decades. Look at the human population today and everyone needs to be on a benzo.

[Bitsy]

6 hours ago, Paula said:

Why would a drug company put a benzo into a polypill of a statin, beta blocker and an aspirin?

Answer: To reduce the anxiety induced by statinitis. 

I chuckled when I saw this, LOL

[Guest Paula]

5 hours ago, GetMeOuttaThisMess said:

Never mind folks. It’s all old joke dating back decades. Look at the human population today and everyone needs to be on a benzo.

Some of us got it.

 

[MedicinePower]

I guess the joke went over my head like the Omega Effect. I am glad this topic was brought up. When Crestor (Rosuvastatin) went generic it opened up a lot of opportunity to treat patients with 1) a high-intensity statin 2) that is non-lipophillic which the research shows causes fewer CNS and muscular issues. Now patients have affordable access to the statin which will help them the most while causing the fewest side-effects and ADRs.

How many out there have Rosuvastatin on their short list for those in whom it is appropriate to initiate statin therapy?