Eliot Brinton, MD, is director of the Metabolism Section of Cardiovascular Genetics and director of the LDL Apheresis Center at the University of Utah School of Medicine in Salt Lake City. Additionally, he is a founding board member of both the National Lipid Association and of the American Board of Clinical Lipidology. He sat down with CardioSource WorldNews Executive Editor Rick McGuire to discuss the largest known cholesterol survey conducted in the United States, involving more than 10,100 statin users. It provides a comprehensive picture of patient and doctor knowledge, attitudes, and concerns about statins.

Rick McGuire: Physicians write about 200 million prescriptions for statins every year, but one-half or more of all patients prescribed statins stop their therapy by the end of the first year. Let's talk about the USAGE survey, which stands for Understanding Statin Use in America and Gaps in Education. Why is adherence such a problem? What did these 10,000 people tell us?
Eliot Brinton, MD: They told us that, by far, the number one reason that they would stop a statin—and many of them had stopped statins—was side effects. Instead of 1-5% of patients in clinical trials who report myopathy, in the real world, we are talking more like 25-50% of patients with side effects and fully half of the patients who stopped statins had stopped because of muscle-related side effects. About one-quarter of those who didn't stop also reported muscle-related side effects.

Do we know if those are actual side effects or perceived side effects? In other words, they've looked at the list of side effects online and say, "Good grief, I'm out of here."
This is a great question and we don't know. There are people who are trying to tease that question apart. In my view, it doesn't matter. Even if it's just a matter of perception, I still have to deal with them on that level if they perceive that problem X is related to their statin.

Right. We've been concentrating a lot on women's health in this country. Are they doing any better than men?
Surprisingly, they are doing poorly, even less well than men. Women were less likely to know their cholesterol level. They were less likely to have any concept of what their LDL cholesterol goal was. They were actually more likely to remember their pant size back in high school than they were their cholesterol level, if you can imagine.

What can physicians do to change the picture that you have just described?
First of all, communication in general is good. I don't think we need to beat up on ourselves too much but there is room for improvement. About 85% of our patients are taking at least one drug that could potentially interact adversely with a statin. So, physicians, pharmacists, and others on the medical team have to recognize the potential for drug-drug interactions because it's extremely common.

Sometimes patients will come to us with their concerns (about other drugs they are taking), but the vast majority of the time, they won't come to us, and when we find an obvious problem with something else they are taking, we ask them: Well, why didn't you go to your doctor about this? And they say, well, we thought our doctor or our pharmacist would come to us. Fair enough, but that means that the burden is on us. We can't expect the patient to be that proactive.

A third of the patients who had stopped statins in our survey did so without ever talking to their doctor. Patients are out there practicing medicine, so what we need to do is make sure the patient comes back to see us far sooner than a year or two after prescribing a statin.

Can computerization help with this drug-drug interaction problem?
The overwhelming majority of pharmacy records are computerized and more physicians are using electronic health records, too. As statin usage goes up, potentially adverse interactions go up, too, but then we've got a serious issue in terms of flagging these and then taking those flags we see on the screen seriously. I started using electronic health records a year ago and I get these little flags on virtually every drug I prescribe and I kind of tune it out. It's a bad habit but we get flag fatigue and then don't pay attention. And sometimes those flags are really serious.

You know a physician can wait for a long time to talk to a pharmacist and vice versa, it happens all the time. So maybe asynchronous communication, like e-mail or chat or whatever that would open these doors a little bit wider—we've got the tools, I just think we need to use them to communicate better between the physician and pharmacist.

In terms of patients being unaware of the LDL level or their goal for therapy, what can you do to improve that? Every time you see a patient on a statin, remind them what their goal is? Remind them what their level is right now? What can you do?
I would encourage all physicians to do that. What I like to do is have it printed out on a piece of paper in front of me and the two of us look at that same number and I point to it, and I say 'OK, here's your number.' And I read it to them so they hopefully can remember it. And I say, 'Here's your goal.' I try to have that on the same flow sheet. If they have achieved their goal it is very important to say, please continue to take your statin because one reason patients stop taking their pills is because they have achieved their goal. They think, 'I met my goal, now I get to stop my drug.'

A key finding in our survey was that patients who could tell their LDL number during an Internet survey were much better off in terms of continuing their statin, being able to endure whatever minor muscle pains they may have, and actually to achieve goal.

What about diet and lifestyle?
I am pleased and proud of the physicians taking care of these 10,000 patients because half of them said that their physician had told them about diet and lifestyle and had told them about it on their last visit. That is wonderful but again, there is room for improvement. We really should be mentioning this every visit, even if just briefly. "Mr. Jones, are you doing your exercise? How are you doing on your diet? Here's your weight. It's gone up. It's gone down." Comment about that. If they are smoking, how many cigarettes are you smoking now? Where are we with our conversation last time about smoking cessation? We can't do every issue at every visit but we need to do something in each visit and make some effort; if we do this, we know from studies it has an incremental effect on improving compliance.

We must never take a casual approach to this. This is life-saving treatment. And for us to be a little more diligent with our patients, to make sure they understand us, they've heard us, they are listening, they are complying.

Tell them there will be a quiz on this.
Absolutely. We don't want to overdo. But I think physicians hopefully have a sense of how much a patient can absorb, how much they can understand, how much they are willing to do and then we take this in, whatever steps the patient will allow us. Of course, some patients are oblivious and there's really nothing we can do. But there is so much more we could do if we just gave a little more thought to this piece.

For more ideas on improving adherence to statin therapy, watch an interview with Eliot Brinton, MD, at youtube.cswnews.org.

Keywords: Electronic Health Records, Drug Interactions, Cholesterol, Life Style, Women's Health, Diet

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