Participation of Women and Older Participants in Randomized Clinical Trials of Lipid-Lowering Therapies: A Systematic Review.

Question Are women and older participants adequately represented in randomized clinical trials of lipid-lowering therapy? Findings In this systematic review of 60 trials with 485 & x202f;409 participants that were conducted between 1990 and 2018, there was a modest increase in the enrollment of women (from 19.5% to 33.6%) and older participants (from 31.6% to 46.2%); however, overall representation was low (28.5% women and 46.7% older adults). Women were underrepresented in trials compared with their relative disease burden. Meaning The results of this study suggest that despite ongoing efforts to increase the representation of women and older participants, these subgroups remained consistently underrepresented in randomized clinical trials of lipid-lowering therapies, limiting the evidence base. This systematic review and meta-analysis determines the trends of representation of women and older patients (>= 65 years) in randomized clinical trials of lipid-lowering therapies from 1990 to 2018. Importance Randomized clinical trials (RCTs) of lipid-lowering therapies form the evidence base for national and international guidelines. However, concerns exist that women and older patients are underrepresented in RCTs. Objective To determine the trends of representation of women and older patients (>= 65 years) in RCTs of lipid-lowering therapies from 1990 to 2018. Data Sources The electronic databases of MEDLINE and ClinicalTrials.gov were searched from January 1990 through December 2018. Study Selection RCTs of lipid-lowering therapies with sample sizes of at least 1000 patients and follow-up periods of at least 1 year were included. Data Extraction and Synthesis Two independent investigators abstracted the data on a standard data collection form. Main Outcomes and Measures Patterns of representation of women and older adults were examined overall in lipid-lowering RCTs and according to RCT-level specific characteristics. The participation-to-prevalence ratio (PPR) metric was used to estimate the representation of women compared with their share of disease burden. Results A total of 60 RCTs with 485 & x202f;409 participants were included. The median (interquartile range) number of participants per trial was 5264 (1062-27 & x202f;564). Overall, representation of women was 28.5% (95% CI, 24.4%-32.4%). There was an increase in the enrollment of women from the period 1990 to 1994 (19.5%; 95% CI, 18.4%-20.5%) to the period 2015 to 2018 (33.6%; 95% CI, 33.4%-33.8%) (P for trend = .01). Among common limiting factors were inclusion of only postmenopausal women or surgically sterile women (28.3%; 95% CI, 18.5%-40.7%) or exclusion of pregnant (23.3%; 95% CI, 14.4%-35.4%) and lactating (16.6%; 95% CI, 9.3%-28.1%) women. Women were underrepresented compared with their disease burden in lipid RCTs of diabetes (PPR, 0.74), heart failure (PPR, 0.27), stable coronary heart disease (PPR, 0.48), and acute coronary syndrome (PPR, 0.51). Only 23 RCTs with 263 & x202f;628 participants reported the proportion of older participants. Overall representation of older participants was 46.7% (95% CI, 46.5%-46.9%), which numerically increased from 31.6% (95% CI, 30.8%-32.3%) in the period 1995 to 1998 to 46.2% (95% CI, 46.0%-46.5%) in the period 2015 to 2018 (P for trend = .43). A total of 53.0% (95% CI, 41.8%-65.3%) and 36.6% (95% CI, 25.6% to 49.3%) trials reported outcomes according to sex and older participants, respectively, which did not improve over time. Conclusions and Relevance In this systematic review of RCTs of lipid-lowering therapies, the enrollment of women and older participants increased over time, but women and older participants remained consistently underrepresented. This limits the evidence base for efficacy and safety in these subgroups.