Medication Therapy Management
Pharmacists Role in Cholesterol Management: Addressing Challenges and Barriers
Journal of Pharmacy Practice 1-9 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190014562384 jpp.sagepub.com
Kendra R. Manigault, PharmD, BCPS, BCACP, CDE1, and Kendra A. Lewis, PharmD, CDE2
Abstract Cholesterol management is an important factor in the modification of primary and secondary cardiovascular events. Guidelines emphasize incorporation of appropriate medication therapy and lifestyle adjustments to reduce low-density lipoprotein cholesterol (LDL-C) for cardiovascular disease (CVD) risk reduction. Of note, studies and nation-wide statistics indicate many patients do not achieve their LDL-C goals. Eliminating barriers and challenges associated with cholesterol management will allow patients to reach prespecified goals for CVD risk reduction. As the nation transitions to covering more individuals, the need for additional health care providers is evident. Pharmacists are accessible and knowledgeable health care contributors who can assist in optimizing patient outcomes. This article discusses the pharmacist’s role in addressing challenges and barriers in cholesterol management. Keywords pharmacists, cholesterol, statins, barriers, challenges
The management of dyslipidemia continues to be a national focus due to its essential role in coronary heart disease (CHD).1 In 2010, CHD caused 1 in 6 deaths within the United States averaging in death every 1 minute 23 seconds.2 Ischemic heart disease and stroke were listed as the 2 top leading causes of death in the world, respectively, in 2011 by the World Health Organization.2 Although medical advancements have likely played a role in decreasing the amount of individuals dying due to ischemic heart disease and stroke, these disease states have remained the top leading causes of death over the last decade.3 Perhaps equally as devastating is the reduced quality of life and life expectancy experienced by patients surviving cardiovascular events as life expectancy has been reported to be reduced up to 15 years and quality of life decreased by 50%.4-8 The economic repercussions of cardiovascular disease (CVD) prove costly as well with an average of 315.4 billion dollars spent on direct and indirect cost in 2010 for CVD and stroke.2 A major goal of CVD prevention is to prevent or delay disease that may result in potentially devastating events. Landmark trials have illustrated the benefit of improving lipid profiles on CVD outcomes in primary and secondary prevention trials.9-12 Lipid-lowering drugs are employed to modify the risk of patients at risk of CVD by decreasing lowdensity lipoprotein cholesterol (LDL-C), the portion of the lipid panel revealed in epidemiologic and clinical studies to be the main cause of CHD.1 The 3-hydroxy-methylglutaryl coenzyme A reductase inhibitors, also known as statins, are the most widely utilized class of lipid-lowering medications due to unequivocal evidence of its benefit in patients with
CVD. Statins are the most potent drugs available for reducing LDL-C levels, lowering plasma cholesterol by 20% to 60%. Additionally, statins’ pleiotropic effects provide benefits to patients independent of the lipid lowering seen in other cholesterol medications.13 Due to the established benefit of lipid-lowering therapy, medication management remains an integral focus in modification of CVD risk. Many factors may contribute to patients not receiving optimal drug therapy for primary and secondary CVD prevention including side effects, drug interactions, nonadherence, failure to titrate to appropriate dose, and inadequate follow-up. Furthermore, the incorporation of lifestyle management is extremely important to modify the risk of primary and secondary CVD events. Additional resources are needed to ensure patients are receiving appropriate care and education as the recommendations for lipid management advances. Pharmacists are well equipped to provide counseling to patients regarding the significance of lifestyle modification, safety and effectiveness of drug therapy, and alternative recommendations as needed. The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III)
1 2
Mercer University, Kaiser Permanente, Atlanta, GA, USA Kaiser Permanente, Atlanta, GA, USA
Corresponding Author: Kendra R. Manigault, Mercer University, Kaiser Permanente, 3001 Mercer University Drive, Atlanta, GA 30341, USA. Email: [email protected]
Downloaded from jpp.sagepub.com at TEXAS SOUTHERN UNIVERSITY on December 12, 2014
2
Journal of Pharmacy Practice
Table 1. Lipid-Lowering Goals and Recommended Low-Density Lipoprotein Cholesterol Levels for Drug Initiation From the National Cholesterol Education Program Interim Report. ATP III 2004 update
Risk
LDL-C goal
Low (0-1 risk factor)
Pharmacists Role in Cholesterol Management: Addressing Challenges and Barriers
Journal of Pharmacy Practice 1-9 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190014562384 jpp.sagepub.com
Kendra R. Manigault, PharmD, BCPS, BCACP, CDE1, and Kendra A. Lewis, PharmD, CDE2
Abstract Cholesterol management is an important factor in the modification of primary and secondary cardiovascular events. Guidelines emphasize incorporation of appropriate medication therapy and lifestyle adjustments to reduce low-density lipoprotein cholesterol (LDL-C) for cardiovascular disease (CVD) risk reduction. Of note, studies and nation-wide statistics indicate many patients do not achieve their LDL-C goals. Eliminating barriers and challenges associated with cholesterol management will allow patients to reach prespecified goals for CVD risk reduction. As the nation transitions to covering more individuals, the need for additional health care providers is evident. Pharmacists are accessible and knowledgeable health care contributors who can assist in optimizing patient outcomes. This article discusses the pharmacist’s role in addressing challenges and barriers in cholesterol management. Keywords pharmacists, cholesterol, statins, barriers, challenges
The management of dyslipidemia continues to be a national focus due to its essential role in coronary heart disease (CHD).1 In 2010, CHD caused 1 in 6 deaths within the United States averaging in death every 1 minute 23 seconds.2 Ischemic heart disease and stroke were listed as the 2 top leading causes of death in the world, respectively, in 2011 by the World Health Organization.2 Although medical advancements have likely played a role in decreasing the amount of individuals dying due to ischemic heart disease and stroke, these disease states have remained the top leading causes of death over the last decade.3 Perhaps equally as devastating is the reduced quality of life and life expectancy experienced by patients surviving cardiovascular events as life expectancy has been reported to be reduced up to 15 years and quality of life decreased by 50%.4-8 The economic repercussions of cardiovascular disease (CVD) prove costly as well with an average of 315.4 billion dollars spent on direct and indirect cost in 2010 for CVD and stroke.2 A major goal of CVD prevention is to prevent or delay disease that may result in potentially devastating events. Landmark trials have illustrated the benefit of improving lipid profiles on CVD outcomes in primary and secondary prevention trials.9-12 Lipid-lowering drugs are employed to modify the risk of patients at risk of CVD by decreasing lowdensity lipoprotein cholesterol (LDL-C), the portion of the lipid panel revealed in epidemiologic and clinical studies to be the main cause of CHD.1 The 3-hydroxy-methylglutaryl coenzyme A reductase inhibitors, also known as statins, are the most widely utilized class of lipid-lowering medications due to unequivocal evidence of its benefit in patients with
CVD. Statins are the most potent drugs available for reducing LDL-C levels, lowering plasma cholesterol by 20% to 60%. Additionally, statins’ pleiotropic effects provide benefits to patients independent of the lipid lowering seen in other cholesterol medications.13 Due to the established benefit of lipid-lowering therapy, medication management remains an integral focus in modification of CVD risk. Many factors may contribute to patients not receiving optimal drug therapy for primary and secondary CVD prevention including side effects, drug interactions, nonadherence, failure to titrate to appropriate dose, and inadequate follow-up. Furthermore, the incorporation of lifestyle management is extremely important to modify the risk of primary and secondary CVD events. Additional resources are needed to ensure patients are receiving appropriate care and education as the recommendations for lipid management advances. Pharmacists are well equipped to provide counseling to patients regarding the significance of lifestyle modification, safety and effectiveness of drug therapy, and alternative recommendations as needed. The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III)
1 2
Mercer University, Kaiser Permanente, Atlanta, GA, USA Kaiser Permanente, Atlanta, GA, USA
Corresponding Author: Kendra R. Manigault, Mercer University, Kaiser Permanente, 3001 Mercer University Drive, Atlanta, GA 30341, USA. Email: [email protected]
Downloaded from jpp.sagepub.com at TEXAS SOUTHERN UNIVERSITY on December 12, 2014
2
Journal of Pharmacy Practice
Table 1. Lipid-Lowering Goals and Recommended Low-Density Lipoprotein Cholesterol Levels for Drug Initiation From the National Cholesterol Education Program Interim Report. ATP III 2004 update
Risk
LDL-C goal
Low (0-1 risk factor)
