Clinical Investigation
Hepatotoxicity Fears Contribute to Underutilization of Statin Medications by Primary Care Physicians

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Abstract

Introduction

The safety and efficacy of hydroxymethylglutaryl CoA reductase inhibitors (statins) have been extensively demonstrated, but in clinical practice, there remains significant underutilization of these medications. The authors hypothesized that this underutilization could stem in part from fear of liver damage caused by statins. The purpose was to determine whether concern about hepatotoxicity acts as a barrier among primary care physicians to prescribing statins for patients with elevated liver transaminase values and/or underlying liver disease.

Method

The survey included 937 primary care physicians from 138 academic centers in the United States, and the following were measured: (1) comparison of statin prescribing for patients with clinical indications and (a) no mention of liver transaminase values, (b) elevated liver transaminase values and (c) underlying liver disease; (2) correlation between perception of statin hepatotoxicity and statin prescribing.

Results

Seventy-one percent of respondents would prescribe statins in scenario 1, (45-year-old woman with low-density lipoprotein 240 mg/dL), whereas only 50% would prescribe statins if the baseline liver transaminase values were elevated to 1.5 times upper limit of normal (P < 0.001). This prescribing rate dropped even further to 40% in scenario 3 (55-year-old man with known coronary disease, low-density lipoprotein 250 mg/dL and hepatitis C). Thirty-seven percent of respondents had falsely elevated perceptions of statin hepatotoxicity risk, and these perceptions correlated inversely with statin prescribing. The method of survey administration prevented calculation of response rate, possibility of response bias exists.

Conclusion

Despite extensive data documenting safety of statins, primary care physicians harbor significant hepatotoxicity concerns, and these concerns act as a barrier to statin utilization.

Section snippets

Survey Sample

We enrolled faculty and resident primary care physicians from university-based medical centers across the United States from December 2008 to April 2009. Physicians with prior training in gastroenterology or hepatology were excluded from the study. This sample was chosen because academic and trainee physicians may be more aware of current guidelines regarding statin use than community physicians.

Participants were recruited by mailing the questionnaire to residency program directors of internal

RESULTS

The survey was mailed to 138 residency program directors as described above, and survey responses were received from 937 physicians. Characteristics of respondents are shown in Table 1.

DISCUSSION

In this nationwide survey of primary care physicians, respondents were less likely to prescribe statins for patients with proven indications if the patient had elevated liver transaminase values, particularly with a diagnosis of hepatitis C. The majority of the respondents indicated that they monitor liver transaminase values more frequently than the guidelines recommend. Many respondents had falsely elevated perceptions of statin hepatotoxicity risk, and these risk perceptions correlated

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    Drs. Rzouq and Volk contributed equally to this study. Each is considered to be the first author of this article.

    This study was supported in part by a grant from the American Gastroenterological Association (to MLV).

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