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Cochrane corner: interventions to improve adherence to lipid-lowering medication
  1. Mieke L van Driel1,
  2. Michael D Morledge2,
  3. Robin Ulep3,
  4. Johnathon P Shaffer4,
  5. Philippa Davies5,6,
  6. Richard Deichmann7
  1. 1 Primary Care Clinical Unit, The University of Queensland, Brisbane, Australia
  2. 2 Family Medicine Residency Program, Middlesex Hospital, Middletown, Connecticut, USA
  3. 3 Department of Internal Medicine, University of Virginia, Charlottesville, Virginia, USA
  4. 4 Department of Internal Medicine, University of Maryland Medical Center, Baltimore, Maryland, USA
  5. 5 The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  6. 6 School of Social and Community Medicine, University of Bristol, Bristol, UK
  7. 7 Department of Internal Medicine, Ochsner Health System, New Orleans, Louisiana, USA
  1. Correspondence to Professor Mieke L van Driel, Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, 4029, Australia; m.vandriel{at}uq.edu.au

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Background

High cholesterol is an important risk factor contributing to the global burden of disease. A WHO report estimated that it accounts for more than one-third of all deaths worldwide, and causes 18% of cerebrovascular disease (CVD) and 56% of ischaemic heart disease.1

The evidence that lipid-lowering drugs can reduce both lipid levels and the risk of heart attacks and strokes is well established. Lipid-lowering medications include statins, fibrates, niacin and bile acid resins. The effectiveness of statins is supported by large randomised trials and meta-analyses2 3 showing that the absolute reduction in LDL-cholesterol is linearly related to a reduction in the incidence of coronary and major vascular events.2 Statins are recommended as first-line therapy, whereas fibrates, niacin and bile acid resins are generally second-line therapy, alone or in combination with statins.4 5

Despite this evidence and the availability of guidelines, lipid-lowering therapy is still underused. Although recommendations about drug treatments vary between countries, most generally recommend statin treatment in people with clinical evidence of CVD to reduce further ischaemic events. In adults who have no history of a cardiovascular event, lipid-lowering medication is recommended if there is a 20% or greater risk of developing CVD in the next 10 years.4 Recommendations by the American College of Cardiology/American Heart Association have recently broadened the indications for lipid-lowering therapy, adding to the challenge of ensuring adequate treatment coverage.5

Adherence to treatment is important for optimal effectiveness. Adherence is defined as the extent to which people take medication as prescribed. A number of factors have been linked to poor adherence, such as lack of knowledge, denial, adverse effects, impaired memory and non-acceptance of treatment. Interventions to improve adherence to medication can focus on the person (patient education), the drug regimen (simplification of regimens), the physician (decision-making aids) …

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