Elsevier

Atherosclerosis

Volume 280, January 2019, Pages 174-182
Atherosclerosis

Trends in statin prescription prevalence, initiation, and dosing: Hong Kong, 2004–2015

https://doi.org/10.1016/j.atherosclerosis.2018.11.015Get rights and content

Highlights

  • Prevalence of statin prescriptions was almost five times higher in 2015 versus 2004.

  • Greater initiation of statins for primary prevention, especially since 2007.

  • Initiation of high-intensity statins is uncommon in Hong Kong.

  • Patients aged 70–84 years had the highest annual statin initiation rates.

Abstract

Background and aims

Clinical practice guidelines recommend specific statin doses for the primary and secondary prevention of cardiovascular disease. Little is known about how statin utilization and dosing have evolved over time in Hong Kong. The aim of this study was to describe trends in statin prevalence, initiation, and dosing from 2004 to 2015.

Methods

Patients receiving public health services, who were prescribed a statin, were included if they received a lipid test at a single center (n = 58,672). Using the territory-wide electronic health record, prescribed daily statin dose, nondaily dose frequency, and statin dose intensity were determined for statin prescriptions from 2004 to 2015. Statin prescription prevalence and initiation rates were estimated using the appropriate at-risk population in the hospital catchment area as the denominator. Prescribed daily doses were stratified by primary or secondary cardiovascular prevention status to assess changes in statin dosing over time.

Results

The prescription prevalence of statins was higher in 2015 (8.68%; 95% CI, 8.60%–8.75%) as compared with 2004 (1.82%; 95% confidence interval [CI], 1.78%–1.86%). Initiation rates for new statin users increased from 2004 to 2013. High-intensity statins were infrequently prescribed. New users generally had higher statin initiation rates for primary prevention. There were small increases in the prescribed daily doses of statins. Nondaily statin dosing was infrequent (0.42% of all prescriptions).

Conclusions

The prevalence and initiation of statin prescriptions increased in Hong Kong, and was in part driven by low-intensity statins for the primary prevention of cardiovascular disease.

Introduction

Statins are effective for primary and secondary prevention of cardiovascular disease [1,2]. In China, cardiovascular disease is the top cause of death [3], while in Hong Kong, heart diseases and cerebrovascular diseases together comprised 1 in 5 of all registered deaths in 2016 [4]. However, scant data are available on the trends in statin prescribing in Hong Kong.

The potential pharmacokinetic differences in Asian populations frequently necessitate a lower statin dose to achieve a comparable cholesterol reduction, as compared with Western populations [5]. In clinical trials [6,7], high-intensity statins caused an increased frequency of adverse effects versus lower intensities. Even moderate doses of simvastatin (40 mg/day) resulted in higher rates of myopathy in Chinese patients in the Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events (HPS2-THRIVE) trial [8], which led to the new regulatory authority recommendations that the lowest dose of simvastatin should be used in Chinese patients [9].

There is also controversy as to whether high-intensity statins provide additional benefits in Asians. In an observational study of 14 866 Japanese patients who underwent their first coronary revascularization [10], the incidence of major adverse cardiovascular events, did not differ between patients prescribed standard statins and “strong” statins. Similarly, 1355 Chinese patients hospitalized for acute coronary syndrome, were randomized to receive a moderate-intensity statin or a high-intensity [11]. After two years of follow-up, there was no statistically significant difference between the two treatment groups. These results suggest that there may not be further clinical benefits to high-intensity statin therapy in most Asians.

Previous local studies show that low- or moderate-intensity statins are commonly prescribed rather than high-intensity statins [[12], [13], [14]]. In light of the evolution of clinical practice guidelines and statin safety concerns, whether there have been changes over time in statin prevalence and initiation has not been investigated in Hong Kong. The objectives of this study were to characterize statin prescription prevalence, statin treatment initiation rates, statin prescription dosing and the cardiovascular prevention status (primary or secondary) of statin users, in a cohort of Hong Kong patients who received a lipid test, between 2004 and 2015.

Section snippets

Data source

We used the data of patients accessing health services within the Hong Kong Hospital Authority: the statutory body that manages all publicly funded hospitals and ambulatory clinics in Hong Kong [15]. The Hospital Authority currently delivers primary, secondary, and tertiary care to the 7.3 million residents of Hong Kong through services at 42 public hospitals, 47 specialist clinics, and 73 general outpatient clinics. Electronic health records, including demographics, inpatient and outpatient

Patient characteristics

A total of 145,875 patients who underwent at least one lipid test between January 2004 and March 2014 were identified. After analyzing their prescription records, 40.2% of adult patients received at least one statin prescription during the observation period, and the majority were classified as primary prevention (Table 1). Most patients (77%) had a recorded lipid test prior to initiating a statin. There were slightly more males than females in the cohort and most patients were aged

Discussion

To our knowledge, this is the first study to report statin prescription prevalence, initiation, and dosing trends in Hong Kong. In 2015, the statin prescription prevalence was nearly five times greater than in 2004, while the statin prescription initiation rate doubled during the 12-year study period. There were also changes in statin drug choices and dosages. The most significant finding is that increases in statin prescribing have been driven by greater use of low- and moderate-intensity

Conflicts of interest

Esther W. Chan has received research funding from The Hong Kong Research Grants Council, The Research Fund Secretariat of the Food and Health Bureau of the Government of the Hong Kong Special Administrative Region, Narcotics Division of the Security Bureau of The Government of the Hong Kong Special Administrative Region, Bristol-Myers Squibb, Pfizer, Bayer and Janssen, a Division of Johnson & Johnson, for work unrelated to this study.

Ian C.K. Wong has received research funding from The Hong

Author contributions

Joseph E. Blais, Conceptualization, Data curation, Formal analysis, Visualization, Writing - original draft.

Esther W. Chan, Conceptualization, Supervision, Data curation, Writing - review & editing.

Sharon W.Y. Law, Formal analysis, Writing - review & editing.

Michael T. Mok, Methodology, Writing - review & editing.

Duo Huang, Writing - review & editing.

Ian C.K. Wong, Writing - review & editing.

Chung-Wah Siu, Conceptualization, Supervision.

Acknowledgements

We would like to thank Mr Jiaxi Zhao for his suggestions regarding data analysis.

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