Background
Cardiovascular (CV) diseases are the leading cause of death in Germany. Although lowering low-density lipoprotein cholesterol (LDL-C) levels is essential for CV risk reduction, only a small proportion of patients achieve their risk-adapted LDL-C targets, due in part to low treatment persistence. Data from a recent retrospective longitudinal analysis highlighted the need for optimizing lipid management with lipid-lowering therapies (LLTs) to address treatment discontinuation amongst patients.¹

Objective
To determine possible reasons for non-persistence to LLTs, identify barriers and possibilities for improving persistence.

Methods
This market research study was conducted among physicians involved in the management of hypercholesterolemia (HC) in Germany between December 9, 2021 – February 1, 2022. Recently published data on the high rates of non-persistence in Germany regardless of treatment were presented to gauge physicians’ awareness and perceptions. Physicians were subsequently surveyed on their perceptions of patients’ persistence, discontinuation and treatment switching rates for statin, ezetimibe, and PCSK9 monoclonal antibody (mAb) therapies, reasons behind patients’ decisions, and factors such as the role of patient awareness of cumulative risk of LDL-C exposure and education, in increasing treatment persistence.

Results
In total, 262 physicians (40% general practitioners [GPs], 21% cardiologists, 12% lipidologists, 17% nephrologists, and 10% angiologists) participated. Physicians’ awareness of patients’ low persistence to LLTs was suboptimal (26%; Figure 1). In this assessment, mean patient persistence beyond 6 months was perceived to be highest with PCSK9 mAb treatment (81%), followed by statins (75%) and ezetimibe (73%), regardless of specialty (Figure 2). Subsequently, mean discontinuation rates were perceived to be 39% for ezetimibe, 38% for statins, and 33% for PCSK9 mAbs. Approximately one in three patients did not switch therapies upon discontinuation, regardless of which LLT they originally received (Figure 3).

Among patients who discontinued treatment ‒ either permanently or to switch to another LLT – the main perceived reasons, as cited by the physicians, were the lack of CV risk awareness/treatment understanding, and patients' fear of side effects, regardless of the LLT prescribed. Other reasons for discontinuation varied between treatments (Figures 4 and 5A‒C).

Patients were generally perceived as having low awareness of the cumulative risk of LDL-C exposure on CV events; 70% of physicians rated patient education on persistence as ‘very important’ in increasing persistence awareness. Longer consultation times, patient education on the risks of elevated LDL-C levels, persistence monitoring, integrating the family in treatment management and cross-disciplinary collaboration between physicians were mentioned as important considerations in increasing patients’ persistence.

Conclusion
This study identified several factors responsible for non-persistence to LLTs in patients with HC, and areas of improvement across primary and specialist care in Germany.

¹Koenig W, Lorenz E, Beier L, Sobottka R, Gouni-Berthold I. Retrospective longitudinal analysis of prescription data to investigate real world adherence and persistence to lipid-lowering therapy in Germany. DGK Herztage 2021. Clin Res Cardiol 110, 1695 (2021).