Improving Your Patients' Adherence to Statin Therapy

Sidney C. Smith, Jr, MD

Professor of Medicine

Director, Center for Cardiovascular Science and Medicine

University of North Carolina School of Medicine

Chapel Hill

The cardiovascular benefits of statins have been unequivocally demonstrated for more than a decade. Statins lower the pro?bability of a fatal or nonfatal coronary event after a myocardial infarction for both men and women and improve cardiovascular outcomes for high- and moderate-risk patients. Despite these benefits, patient adherence to lipid-lowering medications within ¹ year after initiating therapy remains suboptimal. For this reason, physicians? commitment to helping their patients achieve nationally disseminated lipid goals must be strengthened. This article focuses on barriers to adherence to lipid-lowering therapy for patients and their physicians and suggests strategies for improving adherence rates.

Extensive scientific and clinical trial evidence demonstrates that statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) prevent first coronary events, reduce the risk of recurrent events, and improve survival after a myocardial infarction (MI).^1-3 Because of their well-established safety profile and low incidence of side effects, statins are generally the preferred drugs for treating hypercholesterolemia. The National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III guidelines note that statins achieve reductions in low-density lipoprotein cholesterol (LDL-C) of approximately 18% to 55%, depending on the specific agent and dose used.⁴ But despite their proven benefits, statins remain under prescribed and underutilized.⁵ One key factor contributing to the less-than-optimal use of statins and, therefore, effective prevention of coronary heart disease (CHD) is patient adherence (or compliance, often used interchangeably) with recommended therapy5: lipid-lowering regimens will not achieve their potential benefits if they are not followed appropriately.⁶ Patient adherence can be improved by physicians inquiring about patients? compliance with prescribed treatment regimens on each visit and by being certain that each patient understands the goals of treatment.

The Varied State of Adherence to a Drug Regimen

Adherence to medical treatment regimens varies widely and is difficult to measure. An average adherence rate of 50% is cited as typical for most drug regimens, although rates of drug consumption ranging from 0% to more than 100% have also been quoted in the medical literature.⁷ According to pharmaceutical industry data, adherence to therapy (including statins) aimed at preventing cardiovascular disease drops to less than 50% by the end of the first year.⁵ Nonadherence rates include those for patients who stop taking the medicine altogether, as well as those for the 50% of patients receiving treatment who do not take the medication in sufficient quantity or at prescribed intervals.⁵

A national survey of prescription records in Australia (1999-2000) revealed an average 30% discontinuation rate for lipid-lowering drugs; 92% of the prescriptions were for statins.⁸ A Canadian study looked at adherence to therapy among risk-based cohorts of patients aged 66 years or older with acute coronary syndrome, chronic coronary artery disease (CAD), and those receiving medical treatment for the primary prevention of cardiovascular disease.⁹ Adherence in the 3 groups (N = 143,505) progressively declined throughout the 2 years of follow-up (Figure). By 6 months, at least 25% of patients in each risk group had discontinued therapy, although patients in both secondary-prevention cohorts had higher adherence rates than those without evidence of CAD.⁹ Drug costs did not contribute significantly to the results; under the Canadian system, medication requires only a small copayment.

Table 1

Barriers to patient adherence with prescribed medication

Disease-related factors

Asymptomatic disease

Chronic disease

Comorbid disease(s)

Disease requiring long-term change of daily behavior

Medication regimen

Cost

Long-term/lifetime treatment

More than once-daily dosing

Multiple/complex regimens

No perception of benefit/effectiveness

Side effects

Organizational/systemic factors

Insufficient supplementary personnel and resources

Lack of commitment to prevention-oriented activities

Patient-related factors

Female gender

Impaired memory

Lack of belief in being able to change

Perception of being in good health

Smoker

Younger age

Physician-patient relationship

Limited time for counseling

Perceived lack of commitment

Poor communication

Unclear instructions

Factors Influencing Adherence to Medical Therapy

Adherence is a complex issue. Patient-related and disease-related variables, the medical regimen, and the physician-patient relationship may all interact to affect adherence (Table 1). Chronic asymptomatic conditions that require daily behavioral compromises foster poor adherence: hypercholesterolemia and hypertension are 2 well-known examples. Patients with comorbid disease that affects memory or requires multiple drugs generally have problems with adherence. Medication adherence may also decline when a drug must be taken more than once daily.⁶ The problem of nonadherence in the United States may also be magnified by health insurance that is inadequate to cover the high cost of drugs.

Complex regimens that entail behavioral changes strongly predict low adherence.⁷ For example, practice guidelines for type 2 diabetes mellitus may include a special diet, exercise, smoking cessation, oral hypoglycemic drugs, and additional drugs to treat hypertension and/or dyslipidemia. Although this regimen may fulfill the physiologic requirements for optimal care, it also provokes such patient-centered concerns as lifestyle disruptions and drug costs.¹⁰ Few patients can comply closely with such a complex regimen over the long-term.⁷

A study of 193 outpatients with hyperlipidemia?all of whom were prescribed at least 1 lipid-lowering drug?constructed a profile of the typical noncompliant patient.¹¹ Such a patient was more likely to smoke, report frequent adverse effects, have several medications, and miss follow-up appointments and less likely to take the medication as a daily routine. The group?s mean age was 52.7 years, but the least compliant patients averaged 47.1 years.¹¹

Physicians typically rely on their judgment to predict their patients? adherence, often with inaccurate results. Even patients who acknowledge that they have not taken their medications as prescribed substantially overestimate their actual adherence level.⁷ The key question to ask is, ?Have you missed any pills in the past week??⁷ Self-reports of missing 1 or more tablets are equivalent to a medication adherence rate of less than 60%.⁷ Nonadherence should also be suspected when patients do not manifest the expected response to incremental increases in medication.⁷ Practical methods for assessing patient adherence are listed in Table 2.

Nonadherence is generally seen as a patient problem: the physician prescribes, and the patient fails to comply with the prescription.⁵ But the physician-patient relationship may have a powerful influence on adherence to prescribed medication.¹¹ In one study, patients who perceived that their physicians spent more time explaining the links between cholesterol and cardiovascular disease had increased adherence.¹¹ If instructions are not presented clearly, patients may sense that their physicians are uncommitted to a prescribed regimen, resulting in decreased adherence.⁶

Table 2

Methods for assessing patient adherence

Method

Comment

Attendance at follow-up office visits

Missed appointments associated with low adherence

Biologic markers of drug use

Tests generally expensive

Containers that automatically count openings

Not readily available

Drug levels/metabolites in body fluids

May only reflect recent behavior

Medication monitors

Expensive and cumbersome

Pharmacy records

Availability depends on integrated health care system

Self-report (ask patient about missing tablets)

Adherence may be overestimated

Tablet counts

Tedious and time consuming

Treatment response

Lack of response to incremental increases in medication may indicate low adherence level

Sources: References 6 and 7.

Improving Adherence

Approaches to improve adherence that are limited to the patient or physician alone are unlikely to be as successful as those involving the overall setting in which patient-physician interaction occurs.⁵ The system or organization within which clinicians work should provide resources and set policies that support adherence to guidelines and prevention-oriented management.¹² For example, a number of hospital-based programs have been initiated in recent years that have successfully improved institutional adherence to established treatment guidelines, such as the American Heart Association?s (AHA) Get with the Guidelines (GWTG) program,¹³ the American College of Cardiology?s (ACC) Guidelines Applied in Practice (GAP) initiative,¹⁴ and the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative.¹⁵ Examples of resources to aid in improving patient adherence include additional health care professionals (eg, dieticians, nurses, pharmacists) to supplement the more limited time of physicians and office support mechanisms that can facilitate follow-up.^5,12 Nurse-managed, cardiovascular risk-reduction programs have been successful in improving adherence to lipid-lowering therapy and reducing LDL-C levels in primary care and in cardiology practice settings.^16-18

Increased patient satisfaction with care is correlated with increased adherence. Moreover, the stronger the patient?s belief that treatment will be effective, the greater the adherence.¹¹ Patients can be asked to agree to keep appointments by contract, and missed appointments can be addressed with reminders by letter or telephone (Table 3). A complex regimen may need to be simplified to achieve adequate patient adherence.⁷ Adherence-enhancing programs are a topic of continued importance and research, as evidenced by the recent report of a successful online-based adherence/compliance improvement tool in CAD patients.¹⁹

Table 3

Strategies for improving patient adherence

Negotiate goals and priorities with patient

Provide clear oral and written instructions

Provide counseling about importance of regimen

Follow-up

Include additional health care professionals (eg,

dieticians, nurses) in the process

Monitor adherence to medication at each visit, and by:

? Calling patients who have missed appointments

? Contracting with patient to keep appointments

? Reminding patients about appointments with phone calls and/or letters

Physician-specific

Initiate statin therapy with an effective starting dose

Provide statin prescription at hospital discharge

Simplify drug regimen as much as possible

Communicate with patient

The ongoing Open Label Primary Care Study: Rosuvastatin-Based Compliance Initiatives to Achievements of LDL Goals (ORBITAL) includes more than 7500 patients with hypercholesterolemia who have been prescribed a statin.²⁰ Patients are randomized to 2 groups?adherence and a control group. The study group is provided an adherence program consisting of contact with the study center, mailings, telephone calls, and access to a Web site and a hotline. The control group does not include an adherence program. This study should provide further information about the impact of new technology on improving physician compliance to treatment guidelines and patient adherence to therapy.²⁰

Adherence to National Cholesterol Education Program Guidelines

Available data reveal a significant gap between the NCEP LDL-C treatment guidelines and dyslipidemia management in clinical practice.²¹ The Lipid Treatment Assessment Project (L-TAP) demonstrated that many patients with known dyslipidemia who were being treated by primary care physicians were not achieving the NCEP ATP II LDL-C targets. More than 600 participating investigators accounted for 4888 patients treated with lipid-lowering agents.²¹ For those patients, the probability of meeting target levels for LDL-C decreased as the CHD risk level increased. Patients with the lowest risk level (<2 risk factors) had the highest rate (68%) of LDL-C goal achievement (<160 mg/dL), and patients with existing CHD had the lowest rate (18%) of LDL-C target. They were least likely to meet their more stringent LDL-C goal of 100 mg/dL or less.²¹ The L-TAP investigators attributed these results, in part, to low adherence to recommended treatments but also suggested that more powerful lipid-lowering therapies were needed to achieve target goals, especially among high-risk patients.²¹

An outpatient chart audit that incorporated data from 140 medical practices (80% cardiology) to evaluate how closely CAD management practices corresponded to national treatment guidelines showed that only 44% of 48,586 patients with CAD had an LDL-C level noted on their charts within a year of their last visit, and only 25% of those (11% of the total group) had been treated to the NCEP ATP II LDL-C target of 100 mg/dL or less.²² Of the statin-treated patients, 65% were still taking a starting dose.²² Underachievement of therapeutic goals is not just a problem in the United States but has worldwide dimensions, according to results from the Reduction of Atherothrombosis for Continued Health (REACH) registry of adherence data from 43 countries reported at the 2005 ACC meeting.²³

Adherence and Statin Therapy

Despite evidence from large-scale, prospective, randomized clinical trials that statin use is associated with an approximate 30% reduction in the overall risk of major coronary events,¹ and that intensive statin therapy enhances regression of atherosclerotic plaque24 and further decreases CHD risk,²⁵ adherence to statin therapy is often poor.⁵

Receiving a prescription for statin therapy at hospital discharge may increase adherence rates. A prospective study followed 600 patients with hyperlipidemia and angiographically documented severe CAD (>70% stenosis).²⁶ A total of 18% of them were discharged from the hospital with a prescription for a statin. At an average follow-up of 3 years, these patients were almost twice as likely to still be taking a statin compared with those given a prescription at some time after hospital discharge (77% versus 40%, P <.001). Beginning statin therapy at discharge was associated with a significant reduction in mortality at follow-up compared with being discharged from a hospital without statin therapy (5.7% versus 11.7%, P = .05).²⁶ The Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) involved patients with CAD and focused on initiation of secondary-prevention therapy, including aspirin, beta-blockers, and angiotensin-converting-enzyme inhibitors, as well as lipid-lowering therapy with statins, before hospital discharge.²⁷ Patient use of a statin at discharge increased from 6% before the CHAMP program to 86% after the program; furthermore, at 1-year follow-up, statin use had increased to 91%, suggesting high adherence rates. At 6- to 18-month follow-up, 58% of post-CHAMP patients had an LDL-C level of 100 mg/dL or lower, compared with only 6% of pre-CHAMP patients.²⁷ In a study of more than 58,000 post-MI patients, increased adherence was also associated with receiving a statin within 6 months of hospital discharge.²⁸

These studies add to the evidence that adherence-promoting strategies in secondary prevention programs seem most effective when applied early in treatment.⁵ Indeed, a statin prescription at hospital discharge may be one of the most important therapeutic measures offered to hospitalized patients with CAD.²⁶

Nevertheless, because of patient nonadherence, LDL-C reductions in most patients in real-world settings are only about 80% of those achieved in controlled clinical trials.²⁹ As a result, many patients are not achieving their current LDL-C goals.⁵ Failure to achieve LDL-C goals with statin therapy may be caused by use of ineffective statin doses or of less powerful statins; however, up-titrating the statin dose or combining a statin with a fibrate or niacin may result in an increased risk of adverse events.³⁰ Instead, physicians should consider prescribing the starting dose of a statin that produces greater decreases in LDL-C. For example, one study showed that after 12 weeks of therapy, the 10-mg starting doses of atorva?statin calcium (Lipitor) and rosuvastatin calcium (Crestor) can produce LDL-C reductions of up to 39% and 50%, respectively; and after 52 weeks of therapy, up to 44% and 53%, respectively.³¹ These percentage reductions will be sufficient to get many patients to their LDL-C goal.³¹

A 54-week study comparing 5 statins?atorvastatin calcium, fluvastatin sodium (Lescol), lovastatin (Mevacor), pravastatin sodium (Pravachol), and simvastatin (Zocor)?at initial and maximum doses highlights the importance of choosing a starting dose that allows patients to achieve current goals.³² In that study, patients with hypercholesterolemia were grouped according to the ATP II criteria for risk status and LDL target levels and randomly assigned to the lowest recommended starting dose of statin. At each visit (at weeks 6, 12, and 18), the dose was increased if the LDL-C goal was not achieved.³² Results showed the percent LDL reduction attained at the initial dose strongly correlated with the maintenance of NCEP goals by the end of the study.³² Selection of a starting statin dose which will achieve the target goal, therefore, appears to be related to adherence.

The Measuring Effective Reductions in Cholesterol Using Rosuvastatin Therapy (MERCURY I) study evaluated the results of switching high-risk patients with hypercholesterolemia from one statin to another. MERCURY I compared the efficacy of 4 statins (atorvastatin, pravastatin, rosuvastatin, and simvastatin) in lowering LDL-C and reaching European and NCEP ATP III goals.³³ The investigators noted that patients did not undergo a washout period before switching, consistent with physicians? usual prescribing practices.³³ The results of MERCURY I support the use of a starting statin dose that is more likely to get patients to goal rather than to titrate up from lower starting statin doses.

Conclusion

Adherence to lipid-lowering drug regimens is a major problem in clinical practice. The patient with asymptomatic disease, such as hypercholesterolemia, that requires long-term medication may have a problem with adherence. So, too, may the patient who confronts a daily complex regimen of multiple drugs and behavior changes. For patients who have survived an MI, leaving the hospital with a statin prescription promotes adherence.

The compliant patient has a good physician-patient relationship, follows a simplified regimen, and has been well informed about the importance of cholesterol lowering. Communication between patient and physician encourages adherence, but adherence should be further addressed at the organizational and systemic levels. During the first year of therapy, patients? cholesterol levels should be monitored, with dosage adjustments if the LDL-C goal has not been reached. Selecting an efficacious statin that will likely help the patient to achieve LDL-C goals with the initially prescribed dose will allow more patients to reach their LDL-C goals.

Disclosure statement

Dr Smith receives grant/research support from AstraZeneca and has served as a consultant for Bristol-Myers Squibb and Pfizer.

Self-assessment test

1. All the following factors are associated with lack of adherence, except: A. Chronic disease

B. Poor physician-patient relationship

C. Multiple drug regimens

D. Once-daily dosing

2. The profile of a typical noncompliant patient includes all the following characteristics, except: A. Smoker

B. Miss physician appointments

C. Older than 60 years

D. Report frequent side effects

3. All the following actions can help improve patient adherence, except:

A. Providing clear oral and written instructions

B. Simplifying the regimen as much as possible

C. Establishing goals and priorities without consulting the patient

D. Asking about medication adherence at each patient visit

4. Prescribing a statin at hospital discharge after an MI has been shown to:

A. Have no effect on patient adherence to medication

B. Increase patient adherence

C. Reduce patient adherence

D. Result in MI recurrence

5. Which one of the following factors may be res?ponsible for a patient?s failure to achieve current LDL-C goals? A. Being prescribed a subtherapeutic statin dose

B. Using drug therapy

C. Increased risk of adverse events

D. Good rapport with physician

click to view answer

References

1. LaRosa JC, He J, Vupputuri S. Effect of statins on risk of coronary disease: a meta-analysis of randomized controlled trials. JAMA. 1999; 282:2340-2346.

2. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002;360:7-22.

3. Baigent C, Keech A, Kearney PM, et al, for the Cholesterol Treatment Trialists? (CTT) Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins [published correction appears in Lancet. 2005;366:1358]. Lancet. 2005;366:1267-1278.

4. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106: 3143-3421.

5. Ockene IS, Hayman LL, Pasternak RC, et al. Task force #4?adherence issues and behavior changes: achieving a long-term solution. 33rd Bethesda Conference. J Am Coll Cardiol. 2002;40:630-640.

6. LaRosa JC. Poor compliance: the hidden risk factor. Curr Atheroscler Rep. 2000;2:1-4.

7. Haynes RB, McDonald HP, Garg AX. Helping patients follow prescribed treatment: clinical applications. JAMA. 2002;288:2880-2883.

8. Simons LA, Simons J, McManus P, et al. Discontinuation rates for use of statins are high [letter]. BMJ. 2000;321:1084.

9. Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288:462-467.

10. McDonald HP, Garg AX, Haynes RB. Interventions to enhance patient adherence to medication prescriptions: scientific review [published correction appears in JAMA. 2003;289:3242]. JAMA. 2002;288: 2868-2879.

11. Kiortsis DN, Giral P, Bruckert E, et al. Factors associated with low compliance with lipid-lowering drugs in hyperlipidemic patients. J Clin Pharm Ther. 2000;25: 445-451.

12. Miller NH, Hill M, Kottke T, et al. The multilevel compliance challenge: recommendations for a call to action. A statement for healthcare professionals. Circulation. 1997;95:1085-1090.

13. LaBresh KA, Ellrodt AG, Gliklich R, et al. Get with the guidelines for cardiovascular secondary prevention: pilot results. Arch Intern Med. 2004;164:203-209.

14. Mehta RH, Montoye CK, Gallogly M, et al, for the GAP Steering Committee of the American College of Cardiology. Improving quality of care for acute myocardial infarction: the Guidelines Applied in Practice (GAP) Initiative. JAMA. 2002;287: 1269-1276.

15. Bhatt DL, Roe MT, Peterson ED, et al, for the CRUSADE Investigators. Utilization of early invasive management strategies for high-risk patients with non?ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. JAMA. 2004;292:2096-2104.

16. Brown AS, Cofer LA. Lipid management in a private cardiology practice (the Midwest Heart experience). Am J Cardiol. 2000;85:18A-22A.

17. McPherson CP, Swenson KK, Pine DA, et al. A nurse-based pilot program to reduce cardiovascular risk factors in a primary care setting. Am J Manag Care. 2002;8:543-555.

18. Allen JK, Blumenthal RS, Margolis S, et al. Nurse case management of hypercholesterolemia in patients with coronary heart disease: results of a randomized clinical trial. Am Heart J. 2002;144:678-686.

19. Dove JT, Ligon RW, Smith S. Evaluation of computerized quality improvement tool to improve compliance with AHA/ACC guidelines for management of coronary artery disease and post-acute coronary syndrome patients in an outpatient clinic [abstract]. J Am Coll Cardiol. 2005;45:345A. Abstract 844-5.

20. Willich SN, Muller-Nordhorn J, Sonntag F, et al. Economic evaluation of a compliance-enhancing intervention in patients with hypercholesterolemia: design and baseline results of the Open Label Pri?mary Care Study: Rosuvastatin-Based Compliance Initiatives To Achievements of LDL Goals (ORBITAL) study. Am Heart J. 2004;148: 1060-1067.

21. Pearson TA, Laurora I, Chu H, et al. The lipid treatment assessment project (L-TAP): a multicenter survey to evaluate the percentages of dyslipidemic patients receiving lipid-lowering therapy and achieving low-density lipoprotein cholesterol goals. Arch Intern Med. 2000;160:459-467.

22. Sueta CA, Chowdhury M, Boccuzzi SJ, et al. Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease [published correction appears in Am J Cardiol. 1999;84:1143]. Am J Cardiol. 1999;83:1303-1307.

23. Steg PG, Bhatt DL, Ohman EM, et al, on behalf of the REACH registry investigators. Undertreatment of atherothrombotic patients worldwide: baseline data from the REACH Registry [abstract]. J Am Coll Cardiol. 2005;45:390A-391A. Abstract 1070-121.

24. Nissen SE, Tuzcu EM, Schoenhagen P, et al, for the REVERSAL investigators. Effect of intensive compared with moderate lipid-lowering therapy on progression of coronary atherosclerosis: a randomized controlled trial. JAMA. 2004;291:1071-1080.

25. Cannon CP, Braunwald E, McCabe CH, et al, for the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 investigators. Intensive versus moderate lipid lowering with statins after acute coronary syndromes [published correction appears in N Engl J Med. 2006;354:778]. N Engl J Med. 2004;350:1495-1504.

26. Muhlestein JB, Horne BD, Bair TL, et al. Usefulness of in-hospital prescription of statin agents after angiographic diagnosis of coronary artery disease in improving continued compliance and reduced mortality. Am J Cardiol. 2001;87:257-261.

27. Fonarow GC, Gawlinski A, Moughrabi S, et al. Improved treatment of coronary heart disease by implementation of a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP). Am J Cardiol. 2001;87:819-822.

28. Rasmussen JN, Gisiason G, Abildstrom SZ, et al. High continuation rate of statin treatment among patients with acute myocardial infarction [abstract]. J Am Coll Cardiol. 2005;45:220A. Abstract 1090-232.

29. Frolkis JP, Pearce GL, Nambi V, et al. Statins do not meet expectations for lowering low-density lipoprotein cholesterol levels when used in clinical practice. Am J Med. 2002;113:625-629.

30. Schuster H. Improving lipid management?to titrate, combine or switch. Int J Clin Pract. 2004;58:689-694.

31. Olsson AG, Istad H, Luurila O, et al, for the Rosuvastatin Investigators group. Effects of rosuvastatin and atorvastatin compared over 52 weeks of treatment in patients with hypercholesterolemia. Am Heart J. 2002;144:1044-1051.

32. Andrews TC, Ballantyne CM, Hsia JA, et al. Achieving and maintaining National Cholesterol Education Program low-density lipoprotein cholesterol goals with five statins. Am J Med. 2001;111:185-191.

33. Schuster H, Barter PJ, Stender S, et al, for the Effective Reductions in Cholesterol Using Rosuvastatin Therapy I study group. Effects of switching statins on achievement of lipid goals: Measuring Effective Reductions in Cholesterol Using Rosuvastatin Therapy (MERCURY I) study. Am Heart J. 2004;147:705-713.

Practice points

• Despite their proven benefits in reducing low-density lipoprotein cholesterol levels and cardiovascular events, statins remain underprescribed.

• It is well documented that many patients discontinue taking their prescribed medications.

• Explain to the patient the link between adherence to therapy and reaching treatment goals.

• Chronic asymptomatic conditions that require daily behavioral changes, comorbid diseases, and complex drug regimens foster poor adherence.

• Prescribing statin therapy at hospital discharge to patients at risk has been shown to increase adherence.

• Choose an initial statin dose that allows the patient to achieve cholesterol goals to improve adherence.