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Association Between Previous Statin Use and Alzheimer's Disease

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Association Between Previous Statin Use and Alzheimer's Disease brain sciences Article Association between Previous Statin Use and Alzheimer’s Disease: A Nested Case-Control Study Using a National Health Screening Cohort Ji Hee Kim 1 , Heui Seung Lee 1, Jee Hye Wee 2 , Yoo Hwan Kim 3, Chan Yang Min 4 , Dae Myoung Yoo 4 and Hyo Geun Choi 2,* 1 Department of Neurosurgery, College of Medicine, Hallym University, Anyang 14068, Korea; [email protected] (J.H.K.); [email protected] (H.S.L.) 2 Department of Otorhinolaryngology, College of Medicine, Hallym University, Anyang 14068, Korea; [email protected] 3 Department of Neurology, College of Medicine, Hallym University, Anyang 14068, Korea; [email protected] 4 Hallym Data Science Laboratory, College of Medicine, Hallym University, Anyang 14068, Korea; [email protected] (C.Y.M.); [email protected] (D.M.Y.) * Correspondence: [email protected]; Tel.: +82-031-380-3849 Abstract: A number of studies report the incidence of Alzheimer’s disease (AD) in patients taking statins, but the results are inconsistent. (1) Background: The present study investigated the cross- sectional association between previous statin use and the risk of AD development in Korean residents. (2) Methods: We used the Korean National Health Insurance Service-National Sample Cohort; 17,172 AD patients were matched by age, gender, income, and region of residence with 68,688 Citation: Kim, J.H.; Lee, H.S.; Wee, control participants at a ratio of 1:4. We used a multiple conditional logistic regression model J.H.; Kim, Y.H.; Min, C.Y.; Yoo, D.M.; to analyse the association between the number of days of statin use and AD occurrence. Further Choi, H.G. Association between Previous Statin Use and Alzheimer’s analyses were performed to identify whether this association is maintained for different ages, genders, Disease: A Nested Case-Control socioeconomic status groups, and covariates. (3) Results: The odds ratio, which was adjusted for Study Using a National Health potential confounders, for the days of statin use per year in the AD group compared to the control Screening Cohort. Brain Sci. 2021, 11, group was 0.95 (95% confidence interval = 0.92–0.98; p = 0.003). The number of days of statin use 396. https://doi.org/10.3390/ in the AD group was significantly smaller in the subgroups of non-smokers and individuals with brainsci11030396 normal weight, alcohol consumption less than once a week, total cholesterol level below 200 mg/dL, systolic blood pressure below 140, diastolic blood pressure below 90, and fasting blood glucose below Academic Editor: Emilio Portaccio 100 mg/dL. (4) Conclusions: Our results suggest that statin use prevents the occurrence of AD. The effects of statin use in preventing AD may be greater in individuals at relatively low risk. Received: 10 February 2021 Accepted: 18 March 2021 Keywords: Alzheimer’s disease; cholesterol; dementia; neurodegenerative dementia; risk fac- Published: 20 March 2021 tor; statin Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- 1. Introduction iations. Alzheimer’s disease (AD) is the most common form of dementia and the most common cause of neurodegenerative dementia in elderly individuals, accounting for approximately 60% or more of all individuals with dementia [1]. Over 50 million people worldwide are living with dementia, and the number of patients affected is expected to rise to 152 million Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. by 2050 [2]. This rapidly increasing disease burden is challenging healthcare and socioeco- This article is an open access article nomic systems worldwide. Despite substantial research and development investment in distributed under the terms and AD, none of the currently available medications prevents AD or modifies its pathology [3]. conditions of the Creative Commons Therapeutic approaches for disease-modifying effects target the amyloid cascade to prevent Attribution (CC BY) license (https:// the accumulation of toxic amyloid aggregates [4]. However, recent clinical trials in AD, creativecommons.org/licenses/by/ many based on the amyloid hypothesis, were disappointing, and this failure has increased 4.0/). the interest in other potential therapeutic avenues [5]. Brain Sci. 2021, 11, 396. https://doi.org/10.3390/brainsci11030396 https://www.mdpi.com/journal/brainsci Brain Sci. 2021, 11, 396 2 of 11 Statins are the most widely prescribed Food and Drug Administration (FDA)-approved cholesterol-lowering medications [6]. Statins are 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors that reduce cholesterol synthesis and upregulate low-density lipopro- tein (LDL) receptors in hepatocyte membranes, which enables greater clearance of LDL from the bloodstream and lowers the level of lipoproteins [2]. Statins demonstrate var- ious additional effects, including antioxidant, anti-inflammatory, antithrombotic, anti- excitotoxicity, and angiogenesis-promoting effects, improvements in vascular endothelial function, and the modulation of amyloid and tau metabolism [7–10]. Therefore, several studies have examined the possible benefits of statins in preventing or reducing the risk of AD and dementia [9,11,12]. Among all causes of dementia, vascular dementia is more likely to benefit from statins use because it shares the same risk factors as ischemic stroke, and elevated levels of serum total cholesterol and LDL and decreased levels of high-density lipoprotein (HDL) are associated with the risk of vascular dementia [13]. However, the role of statins in the improvement of cognitive function and the prevention of AD is controver- sial. Accordingly, the present study examined the association between previous statin use and the incidence of AD while adjusting for putative risk factors for AD occurrence. We also assessed whether these associations are consistent for different groups in a subgroup analysis stratified by age, gender, socioeconomic factors such as income and region of residence, and baseline medical comorbidities including dyslipidaemia, total cholesterol, obesity, smoking status, alcohol consumption, blood pressure, and fasting blood glucose. 2. Materials and Methods 2.1. Study Population The Institutional Review Board (IRB) of the ethics committee of Hallym University ap- proved this study (IRB No. 2019-10-023). The need to obtain informed consent was waived because of the use of deidentified claims data. All analyses adhered to the guidelines and regulations of the ethics committee of Hallym University. A detailed description of the Korean National Health Insurance Service (NHIS)-Health Screening Cohort data has been delineated elsewhere [14]. 2.2. Patient Selection AD patients were selected from a total of 514,866 participants with 615,488,428 medical claim codes (n = 20,087). The control group comprised all participants who were not dementia patients (n = 494,779). To include AD patients who were diagnosed for the first time, we excluded AD patients who were diagnosed from 2002 to 2003 (washout period, n = 407). Participants were excluded if they were <60 years old (n = 661 for AD patients, n = 179,499 for control participants). Control participants with ICD-10 codes G30 or F00 from 2002 through 2015 were excluded (n = 5209). Participants for whom total cholesterol records (n = 15 for dementia patients), blood pressure records (n = 2 for AD patients), fasting blood glucose records (n = 1 for AD patients), or body mass index (BMI, kg/m2) records (n = 2 for AD patients) were not available were excluded. AD patients were matched with control participants at a ratio of 1:4 for age, gender, income, and region of residence. To curtail selection bias, the control participants were selected in random number order. The index date of each AD patient was set as the time of treatment for dementia. The index date of each control participant was fixed as the index date of their matched AD patient. Therefore, each matched AD patient and control participant had the same index date. During the matching process, 1827 AD patients and 241,383 control participants were excluded. Ultimately, 17,172 AD patients were matched with 68,688 control participants (ratio of 1:4) (Figure1). Brain Sci. 2021, 11, 396 3 of 11 Brain Sci. 2021, 11, x FOR PEER REVIEW 3 of 11 Figure 1. AFigure schematic 1. A illustrationschematic illustration of the participant of the participant selection process selection used process in this used study. in this Of thestudy. total Of 514,866 the participants, 17172 AD patientstotal 514 were866 participants, matched with 17172 68688 AD controlpatients participants were matched for with age, gender,68688 control income, participants and region for of age, residence. “a” gender, income, and region of residence. “a” indicates that AD patients were selected as the partic- indicates that AD patients were selected as the participants assigned G30 or F00 based on ICD-10 codes ≥2 times. AD– ipants assigned G30 or F00 based on ICD-10 codes ≥2 times. AD–Alzheimer’s disease; BMI–body Alzheimer’s disease; BMI–body mass index; CCI–Charlson Comorbidity Index; DBP–diastolic blood pressure; SBP–systolic mass index; CCI–Charlson Comorbidity Index; DBP–diastolic blood pressure; SBP–systolic blood blood pressure.pressure. 2.3. The Number of Days of Statin Use (Exposure) 2.3. The Number of Days of Statin Use (Exposure) The sum of the total days of statin prescription was continuously counted for 2 years The sum of the total days of statin prescription was continuously counted for 2 years (730 days) before the index date. Atorvastatin, fluvastatin, lovastatin, pitavastatin, pravas- (730 days) before the index date. Atorvastatin, fluvastatin, lovastatin, pitavastatin, pravas- tatin, rosuvastatin, and simvastatin were included. tatin, rosuvastatin, and simvastatin were included. 2.4. Alzheimer’s Disease (Outcome) 2.4. Alzheimer’s Disease (Outcome) Participants had AD if they were diagnosed with ICD-10 code G30 or F00 (dementia in ParticipantsAlzheimer’s had AD if disease).they were To diagnosed ensure the with accuracy ICD- of10 the code diagnosis, G30 or F00 we selected(dementia only participants in Alzheimer’swho disease).
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