LDL-cholesterol lowering strategies and population health - time to move to a cumulative exposure model.

Abstract

Lifetime medication burden from current approaches to LDL-cholesterol (LDL-C) lowering is reliant on small molecules requiring daily dosing with the burden of responsibility placed upon patients. Patient-related factors (risk perception, health literacy) impact adherence and persistence. Adherence to statins and ezetimibe correlate with LDL-C reduction and risk, potentially accounting for approximately 12 000 avoidable cardiovascular events per 500 000 patients annually (1). Attempts to improve adherence have had mixed results with only textmessaging reminders, community health worker-based reinforcement and fixed-dose combination pills shown to be effective at improving adherence and clinical events (2). Patienttailored strategies combining multiple approaches including in-person consultations may yield better outcomes, but implementation is complex, consuming both time and resource. Obesity and smoking cessation have been tackled with monetary compensation. Technology offers scalable low-cost options for pill and refill reminders through the use of telephone calls, text-messages, and mobile apps. Finally, a crucial barrier to long-term adherence is the asymptomatic nature of cardiovascular risk factors which may impact medication adherence. This could be facilitated by simplifying access to prescriptions and refills, through electronic healthcare solutions that connect pharmacies to electronic patient records and enable automated prescriptions. Here we draw on population studies and therapeutic developments to potentially address the issue of adherence and lifetime exposure to LDL-C.