Persistence of atorvastatin and simvastatin among patients with and without prior cardiovascular diseases: a US managed care study

ABSTRACT

Background: In clinical practice, persistence with statin therapy is poor. While little is known about relative persistence to specific statins, previous studies have observed greater persistence in patients who achieve greater degrees of lipid lowering. Identification of statin therapies which improve patient persistence has the potential to improve the quality of patient care and clinical outcomes. Therefore, we assessed patient persistence with atorvastatin and simvastatin in primary and secondary prevention patients enrolled in managed care.

Methods: New statin users aged ≥18 years, both with and without prior cardiovascular (CV) events within the 12 month pre-treatment period, were identified from a large national database of managed care patients. Patients initiated atorvastatin or simvastatin therapy from January 1, 2003 to September 30, 2005 and were continuously enrolled in a covered plan for at least 12 months before and after initiation of statin therapy. Subanalyses of patients ≥65 years were also conducted. Measures of interest included demographic and clinical characteristics of the study samples and persistence of statin utilization over the 1-year follow-up period. Persistence was defined as the number of days a patient remained on treatment in the first year following their index date, measured from the date of first fill to study end or the date of discontinuation.

Results: A total of 129 764 atorvastatin users and 45 558 simvastatin users without prior CV events were included in the study. For those patients with prior CV events, a total of 6888 atorvastatin users and 4443 simvastatin users were included in the study. Median persistence in patients without prior CV events was 50 days longer for patients initiating therapy with atorvastatin than simvastatin (207 vs. 157 days, p < 0.0001) and after adjusting for confounding factors, those treated with atorvastatin were 15% less likely to discontinue therapy during the first year than those treated with simvastatin (HR = 0.85; 95% CI 0.84, 0.86; p < 0.001). In secondary prevention patients median persistence was 85 days longer in atorvastatin patients than simvastatin patients (266 vs. 181 days, p < 0.0001) and atorvastatin patients were 22% less likely to discontinue therapy (HR = 0.78; 95% CI 0.75, 0.82; p < 0.001). Persistence was worse in the elderly patients, but the relative difference between atorvastatin and simvastatin was similar to the overall patient population.

Conclusions: In patients with and without prior CV disease, persistence is generally poor, even worse in the elderly, but significantly better for atorvastatin patients than simvastatin patients (p < 0.001). Further studies are required to determine whether this is due to differences in cost, effectiveness, side-effects, or other attributes of the statins.

Study limitations: Differences in persistence could be, in part, due to unmeasured confounders although all available variables were adjusted in multivariate analyses. Additionally, the claims database lacks some clinical data such as lipid levels, limiting assessments of statin efficacy, and does not include any reasons for discontinuation of therapy.     

浅谈医院制剂室持续性实施GPP的方法

目的:持续性实施《医疗机构制剂配制质量管理规范》(GPP),巩固GPP认证成果。方法:介绍我院制剂室GPP认证后加强生产和质量管理的具体做法。结果与结论:通过完善GPP文件系统和促进其实施的制度,健全了生产和质量管理体系,实现了人本管理向文本管理的转变;借助内部微机联网管理加强了生产在线监控和制剂质量管理;员工们对GPP认识的提高,使GPP的各项要求有效地贯彻到制剂生产、管理、保管、发放的全过程、全方面。由此,我院制剂室实现了有效、持续的GPP管理。     

Duloxetine 1 year on: the long-term outcome of a cohort of women prescribed duloxetine

This aim of this study was to determine the long-term persistence with duloxetine in a cohort of women treated for stress incontinence and any alternative treatments undertaken. Two hundred twenty-eight women prescribed duloxetine were initially reviewed after 4 weeks of treatment. Women continuing therapy were reassessed at 4 and 6 months and 1 year with a review of all treatments after 1 year. At each visit, they were asked about persistence with duloxetine, reasons for discontinuation and any alternative treatments. Seventy-one (31%) women continued beyond 4 weeks of treatment, and twenty-six (12%) were taking duloxetine 4 months later, 23 (10%) at 6 months and 21 (9%) at 1 year. One year later, 187 (82%) women had a tension-free vaginal tape operation (TVT). The majority of women discontinued because of side effects (56%) or lack of efficacy (33%). Few women persevere with duloxetine beyond 4 months. One year later, the majority of women had a TVT.     

Persistence of antibodies to West Nile virus nonstructural protein 5

BACKGROUND: Because IgM antibody against West Nile virus (WNV) pre-membrane/envelope (preM/E) recombinant protein may persist for more than 1 year, an assay distinguishing recent from past WNV infection would be useful. Published findings for a single patient suggest that the presence of antibody against WNV nonstructural protein 5 (NS5) indicates recent infection. OBJECTIVES: To compare the persistence of WNV NS5 antibodies and preM/E IgM using plasma samples from blood donors who were viremic at the time of donation. STUDY DESIGN: Follow-up plasma samples from 35 viremic donors were tested for WNV NS5 antibodies using a microsphere immunoassay, and compared to WNV preM/E IgM antibodies determined on the same samples using an enzyme-linked immunosorbent assay (ELISA). RESULTS: At 90+/-14 days of follow-up, 20/26 donors (77%) were positive for NS5 antibodies; 6/25 (24%) were positive at 180+/-27 days, and 3/23 (13%) were positive at 365+/-55 days. The comparable values for preM/E IgM antibodies were 77%, 32% and 17%, respectively. CONCLUSION: Persistence of WNV NS5 antibody in plasma is similar to that of preM/E IgM antibody. WNV NS5 antibody cannot be used to distinguish recent from past WNV infection.     

Roles of PE_PGRS family in Mycobacterium tuberculosis pathogenesis and novel measures against tuberculosis

Tuberculosis remains a serious threat to global public health. As one of the most successful pathogens, Mycobacterium tuberculosis is an adept in evasion the host immune response. M. tuberculosis PE_PGRS family has been widely proposed as molecular mantra to deflect host immunity. The feature of this family is the conserved N-terminal and variable C-terminal. PE_PGRS proteins, with functions largely unknown, are only found among mycobacteria and located in the mycobacterial cell wall and cell membrane. Most PE_PGRS proteins have antigenicity. Polymorphic PGRS domain might play a role in neutralize immune response. Several members of PE_PGRS family have been heterologously expressed for further function characterization. PE_PGRS gene expressing stage-specifically, especially during M. tuberculosis persistence, is promising intervention target to prevent reactivation. The origin, physiological role and spatiotemporal regulation feature of this family remain elusive. The understanding of these questions will shed light on the pathogenesis of M. tuberculosis and facilitate the discovery of new effective antibacterial intervention.     

Psychological factors associated with the incidence and persistence of suicidal ideation

Background

Suicidal ideation has been identified as both a common antecedent and a significant risk factor for suicide attempt and completed suicide. However, little is known about the incidence and persistence of suicidal ideation in the general population and the associated risk factors.

Methods

A 12-month follow-up survey investigated 997 of the respondents who participated in the baseline territory-wide survey of adult population in Hong Kong. A set of baseline psychological factors was considered as predictors of first onset and persistence of suicidal ideation.

Results

Twelve-month incidence (1.9%) and persistence (6.2%) rates were estimated. Respondents with anxiety and lack of reasons for living were more likely to report a development of suicidal thoughts in the follow-up assessment, while respondents with higher level of average life distress and lower level of hope were at increased risk of continuing to have suicidal thoughts. Depression was found to partially mediate the effect of average life distress on persistent suicidality.

Limitations

Retention rate of the follow-up sample was about 50% only. Assessments of suicidal ideation were based on retrospective reports.

Conclusions

Psychological factors differentially predict first onset and persistence of suicidal ideation. It is of clinical value that depression partially mediated the effect of life distress on persistence of suicidality.     

HIV reservoirs and latency models

The main impediment to a cure for HIV is the existence of long-lasting treatment resistant viral reservoirs. In this review, we discuss what is currently known about reservoirs, including their formation and maintenance, while focusing on latently infected CD4+ T cells. In addition, we compare several different in vivo and in vitro models of latency. We comment on how each model may reflect the properties of reservoirs in vivo, especially with regard to cell phenotype, since recent studies demonstrate that multiple CD4+ T cell subsets contribute to HIV reservoirs and that with HAART and disease progression the relative contribution of different subsets may change. Finally, we focus on the direct infection of resting CD4+ T cells as a source of reservoir formation and as a model of latency, since recent results help explain the misconception that resting CD4+ T cells appeared to be resistant to HIV in vitro.