Vivencio Barrios

Cost-effectiveness analysis of rosuvastatin vs generic atorvastatin in Spain

Abstract Objective: The objective of this study was to carry out a long-term cost-effectiveness analysis of rosuvastatin compared with generic atorvastatin in the treatment of patients at high cardiovascular (CV) risk (≥5% Systematic COronary Risk Evaluation [SCORE]) and patients with prior cardiovascular disease (CVD) in Spain. Methods: The efficacy data from the Statin Therapies for Elevated Lipid Levels compared Across doses to Rosuvastatin (STELLAR) study were used to simulate achievement of low-density lipoprotein cholesterol targets with different doses of rosuvastatin and generic atorvastatin for an initial period of 1 year. A Markov model was used to estimate the number of CV complications, quality-adjusted life years (QALYs), and healthcare costs (lipid-lowering treatment and CV events) for up to 20 years after initial treatment. The analysis was carried out from the perspective of the Spanish National Health System, with costs (in year 2010 euros) and effects being discounted at 3% per year. Results: Compared with generic atorvastatin, rosuvastatin was cost-effective (cost per QALY gained of less than €30,000) for the primary prevention of CV events in high-risk patients in most sub-groups analyzed. In patients with prior CVD, rosuvastatin was cost-effective in all sub-groups of men and most sub-groups of women. Key limitations of this study were the need to extrapolate data from a single trial to long-term modeled outcomes and the absence of other treatment options in the analysis. Conclusions: For the treatment of dyslipidemic patients with high CV risk, rosuvastatin is more effective than generic atorvastatin in terms of survival and quality-of-life adjusted survival, with incremental cost-effectiveness ratios within the range generally used in Spain, in most sub-populations defined by various combinations of CV risk factors.

Enfermedad renal crónica y dislipidemia

Chronic kidney disease (CKD) has to be considered as a high, or even very high risk cardiovascular risk condition, since it leads to an increase in cardiovascular mortality that continues to increase as the disease progresses. An early diagnosis of CKD is required, together with an adequate identification of the risk factors, in order to slow down its progression to more severe states, prevent complications, and to delay, whenever possible, the need for renal replacement therapy. Dyslipidaemia is a factor of the progression of CKD that increases the risk in developing atherosclerosis and its complications. Its proper control contributes to reducing the elevated cardiovascular morbidity and mortality presented by these patients. In this review, an assessment is made of the lipid-lowering therapeutic measures required to achieve to recommended objectives, by adjusting the treatment to the progression of the disease and to the characteristics of the patient. In CKD, it seems that an early and intensive intervention of the dyslipidaemia is a priority before there is a significant decrease in kidney function. Treatment with statins has been shown to be safe and effective in decreasing LDL-Cholesterol, and in the reduction of cardiovascular events in individuals with CKD, or after renal transplant, although there is less evidence in the case of dialysed patients.

Selection of the Best of 2016 in Clinical Cardiology: Therapeutic Novelties

1. Desai AS. Intensive management to reduce hospitalizations in patients with heart failure. Circulation. 2016;133:1704–1707. 2. Ding D, Lawson KD, Kolbe-Alexander TL, et al. The economic burden of physical inactivity: a global analysis of major non-communicable diseases. Lancet. 2016. http://dx.doi.org/10.1016/S0140-6736(16)30383-X 3. González-Juanatey JR, Mostaza JM, Lobos JM, Abarca B, Llisterri JL. Un paso más allá en la prevención secundaria del riesgo cardiovascular. Documento de consenso del uso clı́nico del policomprimido. Rev Esp Cardiol. 2016;69:547–550. 4. Björck F, Renlund H, Lip GY, Wester P, Svensson PJ, Själander A. Outcomes in a warfarin-treated population with atrial fibrillation. JAMA Cardiol. 2016;1:172–180. 5. Barrios V, Escobar C, Prieto L, et al. Control de la anticoagulación en pacientes con fibrilación auricular no valvular asistidos en atención primaria en España. Estudio PAULA. Rev Esp Cardiol. 2015;68:769–776. 6. Roldán I, Marı́n F. En el camino de un mejor uso de los anticoagulantes en la fibrilación auricular no valvular. Propuesta de modificación del posicionamiento terapéutico UT/V4/23122013. Rev Esp Cardiol. 2016;69:551–553.

Consenso Delphi sobre el manejo de la dislipidemia en pacientes con alteración del metabolismo de la glucosa: estudio Diana. [Delphi consensus on management of dyslipidaemia in patients with impaired glucose metabolism: Diana study].

OBJECTIVES The aim of the present study was to develop a multidisciplinary consensus based on the Delphi system to establish clinical recommendations for the management of dyslipidaemia when hyperglycaemia is present, and the relevant factors that should be taken into consideration when prescribing and monitoring treatment with statins. METHODS The questionnaire developed by the scientific committee included four blocks of questions about dyslipidaemia in patients with impaired glucose metabolism. The results of the first two blocks are presented here: a) management of dyslipidaemia; b) relevant factors that should be taken into consideration when prescribing and monitoring treatment with statins. RESULTS Among the 497 experts who participated in the study, an agreement of over 90% was attained for recommending screening for dyslipidaemia in patients with diabetes or pre-diabetes and/or cardiovascular disease or a family history and/or abdominal obesity and/or hypertension. There was a high degree of agreement that a statin is the lipid-lowering treatment of choice, and that it should be switched when side effects develop. Also, the choice of statin and dose should be made according to baseline LDL cholesterol levels, the target to achieve, and the possible drug-drug interactions. CONCLUSIONS The screening of dyslipidaemia is primarily conducted in patients with cardiovascular disease, or any major cardiovascular risk factor. When prescribing a statin, physicians mainly focus on the ability to reduce LDL cholesterol and the risk of drug interactions.

Consenso Delphi sobre el manejo de la dislipidemia en pacientes con alteración del metabolismo de la glucosa: estudio Diana

OBJECTIVES The aim of the present study was to develop a multidisciplinary consensus based on the Delphi system to establish clinical recommendations for the management of dyslipidaemia when hyperglycaemia is present, and the relevant factors that should be taken into consideration when prescribing and monitoring treatment with statins. METHODS The questionnaire developed by the scientific committee included four blocks of questions about dyslipidaemia in patients with impaired glucose metabolism. The results of the first two blocks are presented here: a) management of dyslipidaemia; b) relevant factors that should be taken into consideration when prescribing and monitoring treatment with statins. RESULTS Among the 497 experts who participated in the study, an agreement of over 90% was attained for recommending screening for dyslipidaemia in patients with diabetes or pre-diabetes and/or cardiovascular disease or a family history and/or abdominal obesity and/or hypertension. There was a high degree of agreement that a statin is the lipid-lowering treatment of choice, and that it should be switched when side effects develop. Also, the choice of statin and dose should be made according to baseline LDL cholesterol levels, the target to achieve, and the possible drug-drug interactions. CONCLUSIONS The screening of dyslipidaemia is primarily conducted in patients with cardiovascular disease, or any major cardiovascular risk factor. When prescribing a statin, physicians mainly focus on the ability to reduce LDL cholesterol and the risk of drug interactions.

Antihypertensive Medication: On the Right Path?

Having read the interesting letter from Graciano et al, we would like to comment on a number of considerations. First, we feel that, to understand trends and identify areas for improvement, it is imperative that physicians analyze how we prescribe. However, we consider that it is not enough to analyze the number of prescriptions for antihypertensive drugs without putting the issue in the appropriate clinical context. In principle, the increase in prescriptions for antihypertensive agents in recent years is, in itself, neither good nor bad. We believe this increase should have been correlated in some way with the blood pressure control achieved over this period, as well as with the incidences of stroke and ischemic heart disease. In our opinion, there are many reasons for the prescription of more antihypertensive drugs, which include not only population aging (hypertension is more common among elderly patients), but also the greater prevalence of hypertension among young people due to their unhealthy lifestyle habits. This alone would explain the higher number of prescriptions. Fortunately, however, physicians are increasingly aware of the importance of reducing blood pressure to the recommended target levels, including in those patients with mild hypertension. Although clinical trials have been unable to clearly demonstrate any clinical benefits of antihypertensive therapy in patients with mild hypertension, the mean follow-up in these studies was only 2 to 5 years, too short a period to demonstrate benefits in this population. However, these patients will evidently experience more events in the long-term than other individuals of the same age with normal blood pressure. The data from the PRESCAP study show that, over the last decade, hypertension control has improved in Spain, mainly due to more widespread use of combined therapy and to less therapeutic inertia. This has taken place not only in Spain, but also in other western European countries and the United States. Even more importantly, the increased use of combination therapy has reduced the number of cardiovascular events. Where we are in complete agreement with the authors is in that, in Spain, there is still a great deal of room for improvement in blood pressure control. Therefore, although the prescription of antihypertensive drugs has increased in recent years, this rise is probably still insufficient (or the doses used) if what we really want is to achieve acceptable hypertension control in Spain and, as a secondary objective, ensure that our hypertensive patients have fewer cardiovascular complications.