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. 2016 Nov 26;11(11):CD009462.
doi: 10.1002/14651858.CD009462.pub2.

Chronotherapy versus conventional statins therapy for the treatment of hyperlipidaemia

Jose Manuel Izquierdo-Palomares  1 , Jesus Maria Fernandez-Tabera, Maria N Plana, Almudena Añino Alba, Pablo Gómez Álvarez, Inmaculada Fernandez-Esteban, Luis Carlos Saiz, Pilar Martin-Carrillo, Óscar Pinar López
Affiliations

Chronotherapy versus conventional statins therapy for the treatment of hyperlipidaemia

Jose Manuel Izquierdo-Palomares et al. Cochrane Database Syst Rev. .

Abstract

Background: Elevated levels of total cholesterol and low-density lipoprotein play an important role in the development of atheromas and, therefore, in cardiovascular diseases. Cholesterol biosynthesis follows a circadian rhythm and is principally produced at night (between 12:00 am and 6:00 am). The adjustment of hypolipaemic therapy to biologic rhythms is known as chronotherapy. Chronotherapy is based on the idea that medication can have different effects depending on the hour at which it is taken. Statins are one of the most widely used drugs for the prevention of cardiovascular events. In usual clinical practice, statins are administered once per day without specifying the time when they should be taken. It is unknown whether the timing of statin administration is important for clinical outcomes.

Objectives: To critically evaluate and analyse the evidence available from randomised controlled trials regarding the effects of chronotherapy on the effectiveness and safety of treating hyperlipidaemia with statins.

Search methods: We searched the CENTRAL, MEDLINE, Embase, LILACS, ProQuest Health & Medical Complete, OpenSIGLE, Web of Science Conference Proceedings, and various other resources including clinical trials registers up to November 2015. We also searched the reference lists of relevant reviews for eligible studies.

Selection criteria: We included randomised controlled trials (RCTs), enrolling people with primary or secondary hyperlipidaemia. To be included, trials must have compared any chronotherapeutic lipid-lowering regimen with statins and any other statin lipid-lowering regimen not based on chronotherapy. We considered any type and dosage of statin as eligible, as long as the control and experimental arms differed only in the timing of the administration of the same statin. Quasi-randomised studies were excluded.

Data collection and analysis: We used the standard methodological procedures expected by Cochrane. We extracted the key data from studies in relation to participants, interventions, and outcomes for safety and efficacy. We calculated odds ratios (OR) for dichotomous data and mean differences (MD) for continuous data with 95% confidence intervals (CI). Using the GRADE approach, we assessed the quality of the evidence and we used the GRADEpro Guideline Development Tool to import data from Review Manager to create 'Summary of findings' tables.

Main results: This review includes eight RCTs (767 participants analysed in morning and evening arms). The trials used different lipid-lowering regimens with statins (lovastatin: two trials; simvastatin: three trials; fluvastatin: two trials; pravastatin: one trial). All trials compared the effects between morning and evening statin administration. Trial length ranged from four to 14 weeks. We found a high risk of bias in the domain of selective reporting in three trials and in the domain of incomplete outcome data in one trial of the eight trials included. None of the studies included were judged to be at low risk of bias.None of the included RCTs reported data on cardiovascular mortality, cardiovascular morbidity, incidence of cardiovascular events, or deaths from any cause. Pooled results showed no evidence of a difference in total cholesterol (MD 4.33, 95% CI -1.36 to 10.01), 514 participants, five trials, mean follow-up 9 weeks, low-quality evidence), low-density lipoprotein cholesterol (LDL-C) levels (MD 4.85 mg/dL, 95% CI -0.87 to 10.57, 473 participants, five trials, mean follow-up 9 weeks, low-quality evidence), high-density lipoprotein cholesterol (HDL-C) (MD 0.54, 95% CI -1.08 to 2.17, 514 participants, five trials, mean follow-up 9 weeks, low-quality evidence) or triglycerides (MD -8.91, 95% CI -22 to 4.17, 510 participants, five trials, mean follow-up 9 weeks, low-quality evidence) between morning and evening statin administration.With regard to safety outcomes, five trials (556 participants) reported adverse events. Pooled analysis found no differences in statins adverse events between morning and evening intake (OR 0.71, 95% CI 0.44 to 1.15, 556 participants, five trials, mean follow-up 9 weeks, low-quality evidence).

Authors' conclusions: Limited and low-quality evidence suggested that there were no differences between chronomodulated treatment with statins in people with hyperlipidaemia as compared to conventional treatment with statins, in terms of clinically relevant outcomes. Studies were short term and therefore did not report on our primary outcomes, cardiovascular clinical events or death. The review did not find differences in adverse events associated with statins between both regimens. Taking statins in the evening does not have an effect on the improvement of lipid levels with respect to morning administration. Further high-quality trials with longer-term follow-up are needed to confirm the results of this review.

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Conflict of interest statement

Jose Manuel Izquierdo‐Palomares: is member of the board of directors of the Spanish Society of Primary Care Pharmacists (SEFAP), whose financing is through membership fees and also accepts donations from pharmaceutical laboratories. Jesus Maria Fernandez‐Tabera: Grant PI11/02257: “Acción Estratégica de Salud” (2011), Subprograma de proyectos de investigacion en salud. Plan Nacional de Investigación Científica, Desarrollo e InnovaciónTecnológica 2008‐2011(ISCIII), Spain. Grant RS_AP10/5: La cronoterapia frente la terapia convencional en el tratamiento de la hiperlipedemia. Convocatoria de ayudas para el año 2010 de la Agencia Pedro Laín Entralgo de Formación, Investigación y Estudios Sanitarios de la Comunidad de Madrid, para la realización de proyectos de investigación en el campo de resultados en salud en Atención Primaria. Maria N Plana: none known Almudena Añino Alba: none known Pablo Gómez Álvarez: none known Inmaculada Fernandez‐Esteban: from January 1996 to July 1997 Inmaculada Fernández Esteban was employed by Glaxo‐Wellcome as a documentalist. This activity was not related to her work with this Cochrane review. Luis Carlos Saiz: none known Pilar Martin‐Carrillo: none known Óscar Pinar López: none known

Figures

1
1
Study flow diagram
2
2
Risk of bias graph: authors' judgements about each risk of bias item presented as percentages across all included studies
3
3
Risk of bias summary: authors' judgements about each risk of bias item for each included study
1.1
1.1. Analysis
Comparison 1 Lipids (mg/dL), Outcome 1 Total cholesterol (mg/dL).
1.2
1.2. Analysis
Comparison 1 Lipids (mg/dL), Outcome 2 Total cholesterol (mg/dL). Subgroup analysis follow‐up.
1.3
1.3. Analysis
Comparison 1 Lipids (mg/dL), Outcome 3 Total cholesterol (mg/dL). Sensitivity analysis: statistical model (random‐effects).
1.4
1.4. Analysis
Comparison 1 Lipids (mg/dL), Outcome 4 Total cholesterol (mg/dL). Sensitivity analysis: missing data (without Saito 1991).
1.5
1.5. Analysis
Comparison 1 Lipids (mg/dL), Outcome 5 LDL‐C (mg/dL).
1.6
1.6. Analysis
Comparison 1 Lipids (mg/dL), Outcome 6 LDL‐C (mg/dL). Subgroup analysis: follow‐up.
1.7
1.7. Analysis
Comparison 1 Lipids (mg/dL), Outcome 7 LDL‐C (mg/dL). Sensitivity analysis: statistical model (random‐effects).
1.8
1.8. Analysis
Comparison 1 Lipids (mg/dL), Outcome 8 LDL‐C (mg/dL). Sensitivity analysis: missing data (without Saito 1991).
1.9
1.9. Analysis
Comparison 1 Lipids (mg/dL), Outcome 9 HDL‐C (mg/dL).
1.10
1.10. Analysis
Comparison 1 Lipids (mg/dL), Outcome 10 HDL‐C (mg/dL). Subgroup analysis follow‐up.
1.11
1.11. Analysis
Comparison 1 Lipids (mg/dL), Outcome 11 HDL‐C (mg/dL). Sensitivity analysis: statistical model (random‐effects).
1.12
1.12. Analysis
Comparison 1 Lipids (mg/dL), Outcome 12 HDL‐C (mg/dL). Sensitivity analysis: missing data (without Saito 1991).
1.13
1.13. Analysis
Comparison 1 Lipids (mg/dL), Outcome 13 Triglycerides (mg/dL).
1.14
1.14. Analysis
Comparison 1 Lipids (mg/dL), Outcome 14 Triglycerides (mg/dL). Subgroup analysis follow‐up.
1.15
1.15. Analysis
Comparison 1 Lipids (mg/dL), Outcome 15 Triglycerides (mg/dL). Sensitivity analysis: statistical model (random‐effects).
1.16
1.16. Analysis
Comparison 1 Lipids (mg/dL), Outcome 16 Triglycerides (mg/dL). Sensitivity analysis: missing data (without Saito 1991).
2.1
2.1. Analysis
Comparison 2 Adverse events, Outcome 1 At least one adverse event.
2.2
2.2. Analysis
Comparison 2 Adverse events, Outcome 2 At least one serious adverse event.
2.3
2.3. Analysis
Comparison 2 Adverse events, Outcome 3 Myopathy or myotoxicity.
2.4
2.4. Analysis
Comparison 2 Adverse events, Outcome 4 Liver dysfunction.
2.5
2.5. Analysis
Comparison 2 Adverse events, Outcome 5 Gastrointestinal symptoms.
2.6
2.6. Analysis
Comparison 2 Adverse events, Outcome 6 Sensitivity analysis: at least one adverse event.
2.7
2.7. Analysis
Comparison 2 Adverse events, Outcome 7 Sensitivity analysis: at least one serious adverse event.
2.8
2.8. Analysis
Comparison 2 Adverse events, Outcome 8 Sensitivity analysis. Myopathy or myotoxicity.
2.9
2.9. Analysis
Comparison 2 Adverse events, Outcome 9 Sensitivity analysis. Liver disfunction.
2.10
2.10. Analysis
Comparison 2 Adverse events, Outcome 10 Sensitivity analysis. Gastrointestinal symptoms.
3.1
3.1. Analysis
Comparison 3 Compliance with treatment, Outcome 1 Time compliance.
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