Pattern of statin use in several Hospitals in Jakarta. A cross sectional study - Repositori Universitas Kristen Indonesia
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JU R N A L K E D O K T E R A N Y A R SI
1 4 (3 ): 2 2 3 -2 2 9
(2006)
Pattern of stalin use in several Hospitals in Jakarta.A cross sectional study
4D epartm ent of Internal M edicine and Teaching H ospital, C hristian U niversity of Indonesia School of M edicine, Jakarta.
vs 160:t
1 9 9 8 ; H e a rt P ro te c tio n S tu d y C o lla b o ra -tiv e G ro u p , C orrespondence: D r.m ed.A braham Sim afupang, dr.,M K es., D epartm ent of P hannaco- logy and Teaching H ospital, C hristian U niuersity of Indonesia School of M edicine, Jakarta, Jalan M ayjen Sutoyo, C aw ang Jakarta 13630, Telephone (021) 8009190, 8092524, F acsim ile 8093133 E m ail: arm akolo"uki@ allO o.com
1 9 9 7 ). T h e firs t e ffo rt o ffe re d fo r p a tie n ts to lo w e r th e ir c h o le s te ro l le v e l in b lo o d is b y c h a n g in g life s ty le s , w h ic h in c lu d e re d u c in g b o d y w e ig h t, m o re v ig o ro u s d a ily a c tiv ity a n d s m o k in g c e s s a tio n . H o w e v e r, th e s e e ffo rts c o u ld o n ly re d u c e th e c h o le s te ro l le v e l u p to 1 5 % . F o r m o s t o f th e c a s e s , p h a rm a c o lo g ic a l a p p ro a c h , in th e e n d , is c o n s id e re d b y g iv in g a s p e c ific lip id lo w e rin g d ru g . T h e re a re 5 c la s s e s o f lip id -lo w e rin g d ru g s o b ta in a b le i.e . s ta tin s , n ia c in , b ile -a c id s b in d in g re s in s , fib ra te s , a n d c h o le s - te ro l a b s o rp tio n in h ib ito r (e z e tim ib e ) (M a h le y a rid B e rs o t, 2 0 0 1 ]. S ta tin s (3 _ 0 H -3 -m e th y lg lu ta ry l-C o A re d u c ta s e in h ib ito r) a re g ro u p o f lip id lo w e rin g d ru g s , w h ic h a re v e ry e ffe c tiv e in lo w e rin g th e c o ro n a ry a rte ry in c id e n c e s h o w n in m a n y p rim a ry a n d s e c o n d a ry p re v e n tio n s tu d ie s . T h e re a re n o w a t le a s t s e v e n ty p e s o f s ta tin s , w h ic h a re a v a ila b le in th e m a rk e t. T h e firs t o b ta in a b le s ta tin s a re lo v a s ta tin , p ra v a s ta tin a n d s im v a s ta tin , a ll o f w h ic h h a v e s h o w n s o m e re m a rk a b le re s u lts o n lo w e rin g th e in c id e n c e o f c a rd io v a s c u la r d is e a s e s (A n o n y m o u s , 1 9 9 9 ; L IP ID ,
M a n y s tu d ie s re v e a l th a t lo w b lo o d c h o - le s te ro l c o n c e n tra tio n s u b s ta n tia lly lo w e rs th e in c id e n c e o f m y o c a rd in fa rc t a n d a n y o th e r c a r- d io v a s c u la r d is e a s e s (L e v in e et aI, 1 9 9 5 ; H u g h e s
cholesterol level. T he m ost com m on com binations used, w ith respect to atorvastatin, w ere fenofibrate (1 1 .3 % ), pravastatin (9 .3 % ), rosuvastatin (3 % ), gem fibrozil (2 % ), w hereas, w ith regard to rosuvastati, w ere gem fibrozil (9 % ), ciprofibrate (5 % ), and atorvastatin (3 % ). L arge num bers of patients w ere not regularly checked up o r low in com pliance. In conclusion, statins usage in som e hospitals in Jakarta had been inappropriately used, due to m ultiple factors, such as, prescribers, patients' aspects, and the national health system . T herefore, in order to observe the efficacy of statins in clinical setting, a large scale study on the pattern of statin use should be conducted.
III goals on total
71 m g/dL ). A round 4 6 % cases (7 2 out of 2 4 3 cases) m et the N C E P A T P
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K E Y W O R D S statins; efficacy; hypercholesterolem ia; drug com bination A B ST R A C T A prelim inary, cross-sectional study on the pattern of statins use in three hospitals in Jakarta w as conducted to see the responder rate of the patients w ho took statins. D ata w ere taken from the M edical R ecords from M ay-July
0.0001), w hereas triglyceride levels w ere not significantly reduced
A b ra h a m S im a tu p a n g 1 , A d e n a n Iria n t0 2 , W a ld e m a r S im a n ju n ta k 3 , S a h a la P a n g g a b e a n 4 lD epartm ent of P hannacology and Teaching H ospital, C hristian U niversity of Indonesia School of M edicine, Jakarta ZP antai Indah K apuk H ospital, Jakarta 3pertam ina G eneral H ospital, Jakarta
207 :t
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2004 of each hospital. T he inclusion criteria w ere outpatients diagnosed w ith dyslipidem ia treated w ith statins either as first choice or add-on therapy to the other lipid-low ering drugs given. T w o hundred and forty three cases w ere recorded during the 3-m onth period of exam ination, 1 2 7 m ale and 1 1 6 fem ale. T he average age of both group ofpatients w ere 56 :t 1 2 years (m ale) and 5 5 :t 1 2 years (fem ale). T he m ost com m only used statins as first choice and as add-on w as atorvastatin (3 8 .1 % , and 1 .6 % , respectively), follow ed by rosuvastatin (20.5% ), fluvastatin (1 1 .5 % ), pravastatin (10.7% ); w hereas lovastatin (0.4% ) and sim vastatin (3 .7 % ) w ere least prescribed. P atients' total cholesterol levels w ere reduced significantly (2 4 1
38 m g/dL , p <
2 2 4 A B R A H A M S I M A T U P A N G , A D E N A N I R I A N T O , W A L D E M A R S I M A N J U N T A K , S A H A L A P A N G G A B E A N et al.
2 0 0 2 ; B a l l a n t y n e 2 0 0 3 ) . T h e d e v e l o p m e n t o f n e w p a t i e n t s c a m e f r o m t h e s a m e a g e g r o u p . H o w e v e r , g e n e r a t i o n o f s t a t i n s i s e v e r i n c r e a s e d s i n c e t h e l a s t 1 0 t h e r e w a s o n e p a t i e n t w h o s e a g e w a s o n l y 1 7 y e a r s y e a r s ; f l u v a s t a t i n , a t o r v a s t a t i n a n d r o s u v a s t a t i n a r e o l d w i t h t o t a l c h o l e s t e r o l l e v e l 2 4 3 m g / d L . S h e . s o m e o f t h e n e w l y d e v e l o p e d s t a t i n s , w h i c h p r o b a b l y h a d a g e n e t i c t y p e o f h y p e r c h o l e s t e r o l e m i a a c c o r d i n g t o t h e p r o d u c e r s a r e s o m e h o w m o r e w h i c h c o u l d b e a s s e s s e d t h r o u g h g e n o t y p i n g . p o w e r f u l a n d h a v e l e s s s i d e e f f e c t s .
T h e m o s t c o m m o n l y u s e d s t a t i n s a s f i r s t T h o u g h i n m a n y c o n t r o l l e d s t u d i e s , w i t h c h o i c e a n d a s a d d - o n t o t h e s u b s e q u e n t c a s e s w a s v e r y r i g o r o u s p r o t o c o l s , s t a t i n s h a v e p r o v e d t o b e d e p i c t e d i n T a b l e 2 . A t o r v a s t a t i n ( 3 8 . 1% a s f i r s t e f f e c t i v e i n l o w e r i n g c o r o n a r y h e a r t d i s e a s e s ( C H D s ) , c h o i c e a n d 1 . 6 % a s a d d - o n ) s e e m s t o b e t h e m o s t h o w e v e r , t h e u s e o f s t a t i n s i n c l i n i c a l p r a c t i c e p r e s c r i b e d s t a t i n , w h e r e a s l o v a s t a t i n a n d s i m v a s t a t i n e s p e c i a l l y i n d e v e l o p i n g c o u n t r i e s a r e n o t y e t f u l l y w e r e l e a s t p r e s c r i b e d . e x p l o r e d , a l t h o u g h i n d e v e l o p e d c o u n t r y s u c h
T o t a l c h o l e s t e r o l ( T q a n d T r i g l y c e r i d e s ( T G )
et aI,
a s s e s s m e n t h a s b e e n d o n e r e c e n t l y ( p a c k h a m c o n c e n t r a t i o n s w e r e d e p i c t e d i n T a b l e 3 a n d 4 . O n l y 2 0 0 0 ) . T h u s , t h e a i m o f t h e s t u d y w a s t o i n v e s t i g a t e 8 4 o u t o f 2 4 3 c a s e s o f L o w - d e n s i t y l i p o p r o t e i n t h e p a t t e r n o f s t a t i n s ' u s e i n s e v e r a l h o s p i t a l s i n c h o l e s t e r o l ( L D L - q l e v e l w e r e r e g u l a r l y m e a s u r e d ,
J a k a r t a g r e a t e r a r e a . w h e r e a s , t h e m e a s u r e m e n t s o f H i g h - d e n s i t y l i p o p r o t e i n c h o l e s t e r o l ( H D L - C ) w e r e e v e n m o r e
M A T E R I A L S A N D M E T H O D S s c a r c e ( 1 8 c a s e s ) . T h e r e f o r e , d u e t o t h e i n a d e q u a t e d a t a , b o t h l i p o p r o t e i n l e v e l s c o u l d n o t b e s h o w n a n d A c r o s s - s e c t i o n a l d a t a o f m e d i c a l r e c o r d s a n a l y z e d . f r o m M a y t o J u l y 2 0 0 4 w e r e t a k e n f r o m t h r e e p r i v a t e
W i t h r e s p e c t t o t h e N C E P A T P i l l c r i t e r i a o f h o s p i t a l s i n J a k a r t a g r e a t e r a r e a . T h e i n c l u s i o n c h o l e s t e r o l l e v e l s , t h e e f f e c t o f v a r i o u s s t a t i n s o n T C c r i t e r i a f o r s e l e c t i n g a n d c o l l e c t i n g d a t a a r e o u t - a n d T G c o n c e n t r a t i o n s w e r e d e p i c t e d i n F i g . 1 a n d 2 . p a t i e n t s d i a g n o s e d w i t h h y p e r c h o - I e s t e r o l e m i a o r
T h e p e r c e n t a g e o f p a t i e n t s w h o s e T C l e v e l m e e t t h e h y p e r l i p i d e m i a e i t h e r w i t h o r w i t h o u t a n y o t h e r c r i t e r i a o f A T P ( r e s p o n d e r s ) w a s s h o w n i n T a b l e 5 . c o m p l i c a t i o n s o r a c c o m p a - n y i n g d i s e a s e s w h o a r e
A s i t i s o f t e n s e e n i n t h e c l i n i c s , s t a t i n s a r e t r e a t e d w i t h s t a t i n s . T h e s t a t i n s u s e d c a n b e e i t h e r a s u s u a l l y p r e s c r i b e d i n c o m b i n a t i o n w i t h o t h e r l i p i d - f i r s t c h o i c e o r a d d - o n t o a n y o t h e r l i p i d l o w e r i n g l o w e r i n g d r u g s , s u c h a s f i b r a t e s , n i c o t i n i c a c i d a n d d r u g s , s u c h a s f i b r a t e s o r n i a c i n . R e s p o n d e r i s r e c e n t l y w i t h e z e t i m i b e , a s a c h o l e s t e r o l a b s o r p t i o n d e f i n e d a s p a t i e n t w h o s e T o t a l c h o l e s t e r o l l e v e l ( T q i n h i b i t o r . I n t h i s s t u d y , t h i s c o m b i n a t i o n w a s s h o w n d u r i n g o r a f t e r t r e a t m e n t m e e t t h e l e v e l a s i t i s i n T a b l e . 6 . s u g g e s t e d b y t h e N C E P A T P i l l c r i t e r i a . S t a t i s t i c s
A l l s t a t i n s s i g n i f i c a n t l y d e c r e a s e d t h e p l a s m a w e r e u s e d a s l o n g a s d a t a c o l l e c t e d w e r e a p p r o p r i a t e T C l e v e l c o m p a r e d t o t h e p r e t r e a t m e n t l e v e l , b u t n o t u s i n g S P S S v e r s o 1 1 . 0 f o r T G . T h e m o s t f r e q u e n t l y p r e s c r i b e d s t a t i n s w e r e a t o r v a s t a t i n ( 3 9 . 7 % , 9 7 c a s e s ) , r o s u v a s t a t i n ( 2 2 . 5 % , 5 5
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A t f i r s t , 2 5 6 c a s e s w e r e c o l l e c t e d , b u t , a f t e r r e - ( 0 . 4 % , 1 c a s e ) , a n d t h e m o s t f r e q u e n t c o m b i n a t i o n s c r u t i n i z i n g t h e d a t a , f o r l a c k i n g o f i m p o r t a n t i t e m s u s e d f o r a t o r v a s t a t i n w a s f e n o f i b r a t e , w h e r e a s f o r s u c h a s d a t e o f f o l l o w - u p s , d o s a g e , e t c , o n l y 2 4 3 c a s e s r o s u v a s t a t i n w a s g e m f i b r o z i l . w e r e i n c l u d e d f o r t h e s t u d y .
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2 0 0 0 ) . C o m b in a tio n o f s ta tin s a n d o th e r lip id lo w e r in g d r u g s a ls o h a d a b e n e f ic ia l a s p e c t w h ic h c o u ld r e d u c e th e p o s s ib ility o f s ta tin s '
1 9 9 9 ;M a h le y & B e r s o t, 2 0 0 1 ) . _ T h e m e a s u r e m e n t o f th e c o n c e n tr a tio n o f lip o p r o te in c h o le s te r o l s h o u ld c o m p r is e n o t o n ly to ta l c h o le s te r o l, b u t L D L - C a n d H D L - C a s w e ll, e s p e c ia lly f o r p a tie n ts w h o h a d o th e r r is k f a c to r s a s m e n tio n e d in N C E P A T P ill c r ite r ia . I n th is s tu d y , q u ite a lo t o f p a tie n ts h a d b e e n c h e c k e d o n ly f o r th e ir T C le v e l a n d tr ig ly c e r id e le v e l, w h e r e a s th e le v e l o f H D L - C w a s a ls o n o t p r o p e r ly c h e c k e d . T h e r e w e r e 2 8 .2 % ( 4 9 o u t o f 1 7 4 p a tie n ts ) w h o h a d th e ir p r e tr e a tm e n t H D L - C le v e l ~ 4 0 m g / d L ( d a ta w a s n o t s h o w n ) , w h ic h w a s a ls o c o n s id e r e d a s o n e o f th e im p o r ta n t p r e d is p o s in g f a c to r f o r C H D ( B a lla n ty n e et
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2 0 0 4 ) , w h ic h g a v e a g r e a te r p r o p o r tio n o f p a tie n ts to r e a c h th e ta r g e t le v e l a c c o r d in g to th e N C E P A T P ill c r ite r ia . C o s t s h o u ld b e th e n e x t d is c e r n in g f a c to r , if o n c e d r u g tr e a tm e n t is in itia te d , it is a lm o s t a lw a y s lif e lo n g ( U lr ic h
T h e c h o ic e o f s ta tin s s h o u ld b e b a s e d o n e f f ic a c y a n d c o s t. C o u ld th e d o s e o f a p a r tic u la r s ta tin r e d u c e th e p a tie n t's L D L - C to th e ta r g e t le v e l? W ith r e g a r d s to th e d e c r e a s e o f L D L - c h o le s te r o l le v e l, n o w a d a y s , a c o m b in a tio n o f s ta tin s a n d a c h o le s te r o l a b s o r p tio n in h ib ito r i.e . 'e z e tim ib e , w a s p r o v e n to b e s u p e r io r c o m p a r e d to s ta tin s a lo n e o r s ta tin s w ith o th e r lip id - lo w e r in g d r u g s , s u c h a s f ib r a te s . T h e c o m b in a - tio n o f e z e tim ib e a n d s im v a s ta tin c o u ld r e d u c e th e L D L - C le v e l u p to 3 8 % ( G o ld b e r g et al.,
1 9 9 9 ) .F u r th e r m o r e , m o s t o f th e p a tie n ts in I n d o n e s ia w e r e n o t c o v e r e d b y in s u r a n c e , o r p a tie n ts w h o f e lt b e tte r d u e to v a r io u s r e a s o n s w e r e r e f u s e d to c o m e f o r f o llo w u p s ,
et al,
O n th e o th e r h a n d , m a n y c a s e s w e r e d if f ic u lt to r e tr ie v e d u e to ir r e g u la r c h e c k u p s o r n o f o llo w - u p s ; th e r e f o r e , th e s e f a c to r s , a t th e e n d , g a v e a n in c o m p le te in f o r m a tio n o n th e e f f ic a c y o f th e r e s p e c - tiv e s ta tin s . T h e r e w e r e s o m e p o s s ib le a n s w e r s to th is p r o b le m s , i.e . a m o n g o th e r s , la c k o f c o m p r e h e n s iv e in f o r m a tio n f r o m th e c a r e p r o v id e r s to th e p a tie n ts o n th e im p o r ta n c e o f th e c o n tin u ity o f th e d r u g s p r e s c r ib e d , a n d p a tie n ts r e f u s e d to c o m e f o r c h e c k u p s d u e to e c o n o m ic b a c k g r o u n d s ( F a ir h u r s t & H u b y , 1 9 9 8 ;S c h w e d
p r e d is p o s in g f a c to r s , s u c h a s B M I , s m o k in g h a b its , f a m ily h is to r y w e r e n o t v e r y w e ll d o c u m e n te d . A s s u g g e s te d in th e N C E P A T P ill g u id e lin e , a ll th e s e f a c to r s s h o u ld a lw a y s b e ta k e n in to a c c o u n t f o r th e tr e a tm e n t o f d y s lip id e m ia .
al., - 2 0 0 3 ; K r e is b e r g , 2 0 0 2 ; K r e is b e r g , 2 0 0 3 ) . O th e r
et al.,
P A T T E R N O F S T A T I N U S E I N S E V E R A L H O S P I T A L S I N J A K A R T A . A C R O S S S E C T I O N A L S T U D Y 2 2 7
A s w a s d e p ic te d in T a b le 6 , th e r e w e r e 1 1 c a s e s w h e r e c o m b in a tio n o f s ta tin s w ith f ib r a te w e r e u s e d . I n a d d itio n , th e r e w e r e a ls o c o m b in a tio n s o f tw o d if f e r e n t s ta tin s , lik e a to r v a s ta tin w ith p r a v a s - ta tin ( 9 c a s e s ) , a n d a to r v a s ta tin a n d r o s u v a s ta tin ( 3 c a s e s ) . I t w a s w e ll d o c u m e n te d e ls e w h e r e , th a t th e c o m b in a tio n s o f s ta tin s w ith o th e r lip id - lo w e r in g d r u g s , s u c h a s b ile - a c id b in d in g r e s in s , n ia c in w e r e b e n e f ic ia l, b u t, to p u t tw o s ta tin s to g e th e r in o n e th e r a p y r e g im e w a s n o t y e t w e ll p r a c tic e d . U n f o r tu n a te ly , s o m e d r u g c o m b in a tio n s w e r e p r o n e to in te n s if y th e ir s id e e f f e c ts . T h e m o s t f r e q u e n t s id e - e f f e c ts p r e d ic te d w e r e m y o p a th y w h ic h c o u ld le a d to r h a b d o m y o ly s is ( D u e ll et al, 1 9 9 8 ; G a r n e tt, 1 9 9 5 ; M ille r & S p e n c e 1 9 9 8 ) . I n th is s tu d y , it w a s n o t c le a r w h e th e r th e p a tie n ts o b s e r v e d e x p e r ie n c e d s o m e e f f e c ts r e s e m b lin g m y o p a th y , w h ile n o n o tic e s w e r e s e e n in th e m e d ic a l r e c o r d . S o m e s tu d ie s r e v e a le d th a t m y o p a th y a p p a r e n tly o c c u r r e d d u e to p h a r m a - c o d y n a m ic a n d p h a r m a c o k in e tic s in te r a c tio n s ( C o r s in i
s u p p o s e d to b e tr e a te d w ith s ta tin s a c c o r d in g ly r e c e iv e d n o p r o p e r tr e a tm e n t.
al. ( 2 0 0 0 ) . A s s h o w n in th e s e s tu d ie s , p a tie n ts w h o
,
T h e r e s u lts o f m a n y c o n tr o lle d tr ia ls o n d y s lip id e m ia in d ic a te d th a t C H D m o r ta lity w a s r e d u c e d a s m u c h a s 3 0 % to 4 0 % w h e n h y p e r - h o le s te r o le m ic p a tie n ts w e r e tr e a te d w ith m o d e r a te d o s e o f lip id - lo w e r in g d r u g s . T h u s , it w a s v e r y im p o r ta n t th a t th e u ltim a te g o a l f o r tr e a tin g p a tie n ts w ith h y p e r c h o le s te r o le m ia w a s th a t th e ir c h o le s te r o l le v e l c o u ld a c h ie v e th e N C E P A T P ill g o a ls .
( 1 9 9 8 ) , h o w e v e r , s h o w e d th a t a s ig n if ic a n t n u m b e r o f p a tie n ts tr e a te d w ith a to r v a s ta tin r e a c h e d th e ta r g e t L D L c h o le s te r o l le v e l th a n p a tie n ts tr e a te d w ith f lu v a s ta tin a n d lo v a s ta tin . I n th is s tu d y , a to r v a s ta tin w a s th e m o s t f r e q u e n tly p r e s c r ib e d d r u g in th e th r e e h o s p ita ls .
et al.,
( N a s h , 1 9 9 6 ) . B r o w n
D I S C U S S I O N F r o m F ig u r e 1 a n d T a b le 3 w e c a n s e e th a t T C le v e l w a s s ig n if ic a n tly r e d u c e d . B u t, to s o m e e x te n t, th e d e c r e a s e w a s n o t y e t o p tim a l. I n th is s tu d y , th e to ta l c h o le s te r o l a n d tr ig ly c e r id e le v e ls w e r e lo w e r c o m p a r e d to th e p r e tr e a tm e n t le v e l, th o u g h o n ly 4 6 .4 5 % o f p a tie n ts w h o s e to ta l c h o le s te r o l le v e l a c h ie v e d th e N C E P A T P ill g o a l ( S e e T a b le 5 .) . I n c o n tr a s t, a to r v a s ta tin ( 1 7 .4 2 % )s e e m e d to b e th e m o s t s ig n if ic a n t c o n tr ib u to r w h ic h g a v e th e r e s u lt. T h is
- r e s u lt, s u r p r is in g ly , is lo w e r th a n th e o th e r r e s u lt
- U n f m tu n a te ly , a c c o r d in g to P r lm a te s ta et al ( 2 0 0 0 ) , o n ly 1 o u t o f 5 0 E n g lis h a d u lts u s e d a lip id lo w e r in g a g e n t ( 3 0 % o f p e o p le w ith a h is to r y o f c a r d io v a s c u la r d is e a s e a n d 3 % o f p e o p le w ith a 1 0 y e a r r is k o f c o r o n a r y h e a r t d is e a s e o f > 3 0 % ) .A n d th is w a s a ls o c o n f ir m e d b y H u lle y ( 2 0 0 0 ) a n d P a c k h a m et
228
A B R A H A M S I M A T U P A N G ,A D E N A N I R I A N T O ,W A L D E M A RS I M A N J U N T A K , S A H A L AP A N G G A B E A N
N e w i n s i g h t s i n t o t h e p h a r m a c o d y n a m i c a n d p h a r m a - c o k i n e t i c p r o p e r t i e s o f s t a t i n s . P h a r m a c o l . T h e r a p e u t 8 4 : 4 1 3 - 4 2 8 . D u e l l P B , C o n n o r W E , l l I i n g w o r t h D R 1 9 9 8 . R h a b d o m y o l y - s i s a f t e r t a k i n g a t o r v a s t a t i n w i t h g e m f i b r o z i I . A m J
K r e i s b e r g R A , O b e r m a n A 2 0 0 3 . M e d i c a l m a n a g e m e n t o f H y p e r l i p i d e m i a j D y s l i p i d e m i a . J C I i n E n d o c r i n M e t a b o l . 8 8 ( 6 ) : 2 4 4 5 - 2 4 6 1 . K r e i s b e r g R A , O b e r m a n A 2 0 0 2 L i p i d s a n d A t h e r o s c l e - r o s i s : L e s s o n s L e a r n e d f r o m R a n d o m i z e d C o n t r o l l e d
C o m p a r a t i v e d o s e e f f i c a c y s t u d y o f a t o r v a s t a t i n v e r s u s s i m v a s t a t i n , p r a v a s t a t i n , l o v a s t a t i n , a n d f I u v a s t a t i n i n p a t i e n t s w i t h h y p e r c h o l e s t e r o l e m i a ( t h e C U R V E S s t u d y ) . A m J C a r d i o l . 8 2 : 5 8 2 - 5 8 7 . J o n e s P H , D a v i d s o n M R , S t e i n E A e t a l . 2 0 0 3 . C o m p a r i s o n o f t h e e f f i c a c y a n d s a f e t y o f r o s u v a s t a t i n v e r s u s a t o r v a s t a t i n , s i m v a s t a t i n , a n d p r a v a s t a t i n a c r o s s d o s e s ( S T E L L A R *T r i a l ) . A m . J C a r d i o l . 9 2 : 1 5 2 - 1 6 0 . J o k u b a i t i s L A 1 9 9 6 . F l u v a s t a t i n i n c o m b i n a t i o n w i t h o t h e r l i p i d - l o w e r i n g a g e n t s . B r . J C l i n P r a t t S u p p l 7 7 a : 2 8 - 3 2
J o h a n n e s s o n M , J o n s s o n B , K j e k s h u s J e t a l . 1 9 9 7 . C o s t E f f e c t i v e n e s s o f S i m v a s t a t i n T r e a t m e n t t o L o w e r C h o l e s t e r o l L e v e l s i n P a t i e n t s w i t h C o r o n a r y H e a r t D i s e a s e . N E n g J M e d . 3 3 6 : 3 3 2 - 3 3 6 . J o n e s P , K a f o n e k S , L a u r o r a I , H u n n i n g h a k e 1 9 9 8 .
H u g h e s K 1 9 9 7 . S c r e e n i n g f o r a n d t r e a t m e n t o f h y p e r c h o - l e s t e r o l a e m i a - A r e v i e w . A n n a l s A c a d . M e d i c . 2 6 : 2 1 5 - 2 2 0 . H u l l e y S B , G r a d y 0 , B r o w n e r W S 2 0 0 0 . S t a t i n s : u n d e r u s e d b y t h o s e w h o w o u l d b e n e f i t B M J .3 2 1 :
M a y o C l i n P r o c . 7 9 : 6 2 0 - 6 2 . H e a r t P r o t e c t i o n S t u d y C o l l a b o r a t i v e G r o u p 2 0 0 2 . M R C j B H F H e a r t P r o t e c t i o n S t u d y o f c h o l e s t e r o l l o w e r i n g w i t h s i m v a s t a t i n w i t h 2 0 5 3 6 h i g h - r i s k i n d i v i d u a l s : a r a n d o m i z e d p l a c e b o - e o n t r o l l e d t r i a l . L a n c e t 3 6 0 : 7 - 2 2 .
S y s t P h a r m 5 2 : 1 6 3 9 - 1 6 4 5 . G o l d b e r g A C , S a p r e A , L i u J , C a p e c e R , e t a t E f f i c a c y a n d S a f e t y o f E z e t i m i b e C o a d m i n i s - t e r e d W i t h S i m v a s t a t i n i n P a t i e n t s W i t h P r i m a r y H y p e r c h o l e s t e r o l e m i a : A R a n d o m i z e d , D o u b l e - B l i n d , P l a c e b o - C o n t r o l l e d T r i a l .
B M J .3 1 7 : 1 l 3 D - 1 l 3 4 . G a r n e t t W R . 1 9 9 5 . I n t e r a c t i o n s w i t h h y d r o x y m e t h y l g I u - t a r y l - e o e n z y m e A r e d u c t a s e i n h i b i t o r s . A m J H e a l t h
C a r d i o l 8 1 : 3 6 8 - 3 6 9 . F a i r h u r s t K , H u b y G 1 9 9 8 . F r o m t r i a l d a t a t o p r a c t i c a l k n o w l e d g e : q u a l i t a t i v e s t u d y o f h o w g e n e r a l p r a c t i - t i o n e r s h a v e a c c e s s e d a n d u s e d e v i d e n c e a b o u t s t a t i n d r u g s i n t h e i r m a n a g e m e n t o f h y p e r c h o l e s t e r o l e m i a .
1 9 9 8 . T r e a t i n g p a t i e n t s w i t h d o c u m e n t e d a t h e r o s - c l e r o s i s t o N a t i o n a l C h o l e s t e r o l E d u c a t i o n P r o g r a m r e c o m m e n d e d l o w - d e n s i t y l i p o p r o t e i n c h o l e s t e r o l g o a l s w i t h a t o r v a s t a t i n , f I u v a s t a t i n , l o v a s t a t i n a n d s i m v a s t a t i n . J A m C o l l C a r d i o l ; 3 2 : 6 6 5 - 6 7 2 . C o r s i n i A , B e l l o s t a S , B a e t t a R , F u m a g a l l i R , e t a l . 1 9 9 9 .
s i d e e f f e c t s w h i l e t h e s t a t i n d o s a g e u s e d i n c o m b i n a - t i o n w a s l o w e r t h a n s t a t i n m o n o t h e - r a p y .
E f f e c t o n h i g h - d e n s i t y l i p o p r o t e i n c h o l e s t e r o l o f m a x i m u m d o s e s i m v a s t a t i n a n d a t o r v a s t a t i n i n p a t i e n t s w i t h h y p e r c h o l e s t e r o l e m i a : R e s u l t s o f t h e C o m p a r a t i v e H D L E f f i c a c y a n d S a f e t y S t u d y ( C H E S S ) . A m H e a r t J . 4 6 : 8 6 2 - 8 6 9 . B r o w n A S , B a k k e r - A r k e m a R G , Y e l l e n L , H e n l e y R W , e t a l .
A n o n y m o u s 1 9 9 4 . R a n d o m i s e d t r i a l o f c h o l e s t e r o l l o w e r i n g i n 4 4 4 4 p a t i e n t s w i t h c o r o n a r y h e a r t d i s e a s e : t h e S c a n d i n a v i a n S i m v a s t a t i n S u r v i v a l S t u d y ( 4 5 ) . L a n c e t 3 4 4 : 1 3 8 3 - 1 3 8 9 . B a l l a n t y n e C M , B l a z z i n g M A , H u n n i n g h a k e D B , e t a l . 2 0 0 3 .
R E F E R E N C E S
N a i b o r h u , N s . Y u n i S u l i s t y o w a t i , f o r t h e i r e f f o r t s i n c o l l e c t i n g t h e d a t a f r o m t h e m e d i c a l r e c o r d . T h e s t u d y w a s f u n d e d b y D I G M ( G e r m a n I n d o n e s i a M e d i c a l S o c i e t y ) a n d F a c u l t y o f M e d i c i n e o f U n i v e r s i t a s K r i s t e n I n d o n e s i a .
A C K N O W L E D G E M E N T T h e a u t h o r s w i s h t o t h a n k M s . L i e n
I n d o n e s i a , t h u s , t h e e f f i c a c y a n d o t h e r b e n e f i c i a l a s p e c t s o f s t a t i n s c o u l d b e r i g o r o u s l y m e a s u r e d .
T r i g l y c e r i d e l e v e l ( A T P l l I ) . A p r o s p e c t i v e l a r g e s c a l e s t u d y s h o u l d b e p e r f o r m e d t o a s s e s s t h e p a t t e r n u s e o f s t a t i n s w i t h r e s p e c t t o c l i n i c a l s e t t i n g s i n
C O N C L U S I O N A c r o s s - s e c t i o n a l s t u d y o f p a t t e r n u s e o f s t a t i n s i n s e v e r a l h o s p i t a l i n J a k a r t a w a s c o n d u c t e d . A l t h o u g h t o t a l c h o l e s t e r o l l e v e l s d e c r e a s e d s i g n i f i c a n t l y , t h e r e s p o n d e r s r a t e w a s s t i l l s m a l l . T h e d o s e o f s t a t i n s ( r o s u v a s t a t i n , f l u v a s t a t i n ) n e e d s t o b e i n c r e a s e d t o m e e t t h e t h e r a p e u t i c g o a l i n l o w e r i n g
T h e u s e o f e v i d e n c e f r o m c o n t r o l l e d c l i n i c a l t r i a l s t o s u p p o r t r o u t i n e p r a c t i c e w a s o b v i o u s t o b e a k e y f a c t o r o f a c h i e v i n g a c o s t e f f e c t i v e h e a l t h s e r v i c e ( V a n H o u t a n d S i m o o n s , 2 0 0 1 ) . T r e a t m e n t g u i d e l i n e s o f f e r t h e p r e s c r i b e r s a r a t i o n a l w a y t o c h o o s e a n d m a i n t a i n t h e i r t r e a t m e n t f o r p a r t i c u l a r d i s e a s e s , i n c l u d i n g h y - p e r l i p i d e m i a , b u t , n e v e r t h e l e s s , d o c t o r s s h o u l d p u r s u e t h e n e w t r e n d s a n d d e v e l o p m e n t s i n t h e i r r e s p e c t i v e a r e a s , a s i n t h e t r e a t m e n t o f l i p i d d i s o r d e r s . T h e d e v e l o p m e n t a n d u s e o f s t a t i n s w e r e a n e x a m p l e o f t h e v e r y r a p i d p r o g r e s s i o n i n t h e m a n a g e m e n t o f d y s l i p i d e m i a .
T r i a l s o f L i p i d L o w e r i n g a n d O t h e r R e l e v a n t S t u d i e s . J C o o E n d o c r i n M e t a b o l . 8 7 ( 2 ) :4 2 3 - 4 3 7 . L a w M R , W a l d N J , R u d n i c k a A R 2 0 0 3 . Q u a n t i f y i n g e f f e c t o f s t a t i n s o n L o w D e n s i t y L i p o p r o t e i n C h o l e s t e r o l , l s c h a e m i c H e a r t D i s e a s e , a n d S t r o k e : S y s t e m a t i c R e v i e w a n d M e t a - a n a l y s i s . B M J .3 2 6 : 1 - 7 . http://www.univpancasila.ac.id 7/27 P A T I E R N O F S : : r A T I NU S E I N S E V E R A L H O S P I T A L SI N J A K A R T A .A C R O S S S E C T I O N A LS T I J D Y . 2 2 9 L e v i n e G N , K e a n e y J F a n d V i t a J A 1 9 9 5 . C h o l e s t e r o l r e d u c - t i o n i n c a r d i o v a s c u l a r d i s e a s e . C l i n i c a l b e n e f i t s a n d p o s s i b l e m e c h a n i s m s . N e w E n g l J M e d ; 3 2 2 : 5 1 2 - 5 2 1 . L o n g T e r m I n t e r v e n t i o n w i t h P r a v a s t a t i n i n I s c h a e m i c D i s e a s e ( L I P I D ) S t u d y G r o u p 1 9 9 8 . P r e v e n t i o n o f c a r d i v a s c u I a r e v e n t s a n d d e a t h w i t h p r a v a s t a t i n i n p a t i e n t s w i t h c o r o n a r y h e a r t d i s e a s e a n d a ! > r o a d r a n g e o f i n i t i a l c h o l e s t e r o l l e v e l s . N e w E n g l J M e d ; 3 3 9 : 1 3 4 9 - 5 7 . M a h l e y R W , B e r s o t T P 2 0 0 1 . D r u g T h e r a p y f o r H y p e r c h o - l e s t e r o l e m i a a n d D y s l i p i d e m i a i n J G H a r d m a n , L E
L i m b i r ~ a n d A G G i l m a n ( e d s . ) : G o d d m a n & G i l m a n 's t h e P h a r m a c o l o g i c a l B a s i s o f T h e r a p e u t i c s . N e w Y o r k : M c G r a w - H i l l , p 9 7 1 - 1 0 0 2 . M i l l e r D B a n d S p e n c e , J D 1 9 9 8 . C l i n i c a l p h a r m a c o k i n e t i c s o f f i b r i c a c i d d e r i v a t i v e s ( f i b r a t e s ) . C l i n P h a r m a c o k i n e t
3 4 : 1 5 5 - 1 6 2 N a t i o n a l I n s t i t u t e o f H e a l t h 2 0 0 1 . T h i r d R e p o r t o f t h e N a t i o n a l C h o l e s t e r o l E d u c a t i o n P r o g r a m ( N C E P ) E x p e r t P a n e l o n D e t e c t i o n , e v a l u a t i o n , a n d t r e a t t n e n t o f h i g h b l o o d c h o l e s t e r o l i n a d u l t s ( A d u l t s T r e a t m e n t P a n e l I I I ) . , "
N a s h D T 1 9 9 6 . M e e t i n g n a t i o n a l c h o l e s t e r o l e d u c a t i o n g o a l s i n c l i n i c a l p r a c t i c e - a c o m p a r i s o n o f l o v a s t , a t i n a n d f l u v a s t a t i n i n p r i n i a r y p r e v e n t i o n . A m J C a t d i o l ; 7 8 : 2 6 - 3 1 .
" ,
P a c k h a m C , P e a r s o n J , R o b i n s o n J , G r a y D 2 0 0 0 . U s e o f s t a t i n s i n g e n e r a l p r a c t i c e s , 1 9 9 6 - 8 : c r o s s - s e c t i o n a l s t u d y . B M J . 3 2 0 : 1 5 8 3 - 1 5 8 4 . P r i m a t e s t a P , P o u l t e r N R 2 0 0 0 . L i p i d c o n c e n t r a t i o n s a n d t h e u s e o f l i p i d l o w e r i n g d r u g s : e v i d e n c e f r o m a n a t i o n a l c r o s s s e c t i o n a l s u r v e y . B M J . 3 2 1 : 3 2 2 - 3 2 5 . S c h w e d A , F a l l a b C L , B u r n i e r M , W a e b e r B , e t a l . 1 9 9 9 .
E l e c t r o n i c m o n i t o r i n g o f c o m p l i a n c e t o l i p i d - l o w e r i n g t h e r a p y i n c l i n i c a l p r a c t i c e . J C l i n P h a r m a c o l ; 3 9 : 4 0 2 - 4 0 9 . S i g u r d s s o n G , H a r a l d s d o t t i r S O , M e l b e r g T H , e t a l . 1 9 9 8 .
S i m v a s t a t i n c o m p a r e d t o f l u v a s t a t i n i n t h e r e d u c t i o n o f s e r u m l i p i d s a n d a p o l i p o p r o t e i n s i n p a t i e n t s w i t h i s c h a e m i c h e a r t d i s e a s e a n d m o d e r a t e h y p e r c h o l e s - t e r o l a e m i a . A c t a C a r d i o l ; 5 8 : 7 - 1 4 . S t e i n E S 2 0 0 3 . T h e P o w e r o f S t a t i n s : A g g r e s s i v e L i p i d L o w e r i n g . C l i n C a r d i o l . 2 6 ( S u p p l . I I I ) : i l l - 2 5 - i l l 3 1 . U l r i c h S , H i n g o r a n i A D , M a r t i n J , V a l l a n c e P 2 0 0 0 . W h a t i s t h e o p t i m a l a g e f o r s t a r t i n g l i p i d l o w e r i n g t r e a t m e n t ?
A m a t h e m a t i c a l m o d e l . B M J ; 3 2 0 : 1 1 3 4 - 1 1 4 0 . V a n H o u t B A a n d S i m o o n s M L 2 0 0 1 . C o s t - e f f e c t i v e n e s s o f H M G c o e n z y m e r e d u c t a s e i n h i b i t o r s . W h o m t o t r e a t ?
E u r o p e a n H e a r t J o u r n a l 2 2 , 7 5 1 - 7 6 1 . W h i t e R D , S i m e s J , A n d e r s o n M E , e t a l . 2 0 0 0 . P r a v a s t a t i n T h e r a p y a n d t h e R i s k o f S t r o k e . N E n g J M e d . 3 4 3 : 3 1 7 -
2 6 .