Initiating Statin Therapy in the Primary Care Setting

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The MD Magazine Peer Exchange “Amassing the Clinical Evidence for Optimized Dyslipidemia Management: Vitamin D, Long-Term Statin Outcomes, and PCSK9 Inhibition” features expert insight and analysis of the latest information on managing hypertension and hyperlipidemia, and in-depth discussion on the use of PCSK9 inhibitors in practice.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

• Christie Ballantyne, MD, Co-director of the Lipid Metabolism and Atherosclerosis Clinic at The Methodist Hospital, Director of the Center for Cardiovascular Disease Prevention at the Methodist DeBakey Heart Center, and the Chief of Cardiology at Baylor College of Medicine
• Keith C. Ferdinand, MD, Immediate Past Chair of the National Forum for Heart Disease and Stroke Prevention, and Professor of Clinical Medicine at the Heart and Vascular Institute at Tulane University School of Medicine
• Jennifer G. Robinson, MD, MPH, Professor in the Departments of Epidemiology & Medicine and Director of the Prevention Intervention Center, Department of Epidemiology at the College of Public Health, University of Iowa
• Karol E. Watson, MD, PhD, Professor of Medicine and Cardiology, Co-director of the UCLA Program in Preventive Cardiology, and Director of the UCLA Barbra Streisand Women’s Heart Health Program

Dr. Ballantyne said the guidelines for statin prescribing actually allow starting patients at a lower dose of atorvastatin (40 mg vs. 80 mg). The important thing is for physicians to have a conversation with their patients who may be worried about side effects from the higher dose and explain that the lower dose of atorvastatin will give them most of the benefits associated with the higher recommended dose.

Most patients are not started on the higher dose, said Dr. Ferdinand. By way of example, he said that when patients with vascular disease and prior history of myocardial infarction go to their primary care provider, they’re not started on atorvastatin 80 mg. “The prescription data, if you look at big pharmacy benefit packages, don’t show the 80 as a starting dose in basically anybody other than those that are started in the hospital with acute coronary syndrome,” he said.

Dr. Salgo asked what should be done with a patient who doesn’t fit the same profile as the patients in the studies (ie, no history of serious acute coronary syndrome, coronary artery disease, stroke, or peripheral vascular disease) but who has LDL levels of 150 mg/dL? “Is it wrong to start them at a lower dose?” he asked.

It would be wrong because most physicians do not up-titrate and by starting them at the lower dose “you’re denying your patient evidence-based therapy,” said Dr. Robinson.

The guidelines got this right, said Dr. Ballantyne, because they say, “see what the risk is and then you could start at a moderate dose on these people. Just because the LDL is 150 doesn’t mean that they’re high risk. They may fall into a different category.” In fact, he thinks the problem has been undertreatment, not overtreatment.

“Patient preference has to be a part of the clinician patient discussion,” agreed Dr. Watson.