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Statin intensification sufficient for most with atherosclerotic CVD
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Most individuals with atherosclerotic CVD could reach an LDL level of less than 70 mg/dL with intensification of oral lipid-lowering therapy, with only a small amount requiring a PCSK9 inhibitor, according to a study published in JAMA Cardiology.
Christopher P. Cannon, MD, senior physician at Brigham and Women's Hospital and professor of medicine at Harvard Medical School, and colleagues identified a cohort of 105,269 participants (57% men; mean age, 65 years) with atherosclerotic CVD from a database of U.S. medical and pharmacy claims from 2012 to 2013. For the simulation cohort, the researchers used replacement (in the bootstrapping method) to enter 1 million participants into a Monte Carlo simulation.
Those not receiving statins were given atorvastatin 20 mg. Intensification occurred in the following sequence: up-titration to atorvastatin 80 mg; add-on ezetimibe therapy; add-on alirocumab (Praluent, Sanofi/Regeneron) 75 mg; and up-titration to alirocumab 150 mg.
Before treatment intensification, in the simulation cohort of 1 million patients (55% men; mean age, 66 years), 51.5% used statin monotherapy and 1.7% used statins plus ezetimibe, and 25.2% reached an LDL level of less than 70 mg/dL.
After lipid-lowing treatment intensification, 99.3% could reach an LDL level less than 70 mg/dL, according to the simulation. This level was reached in 67.3% of participants with statin monotherapy, in 18.7% with statins plus ezetimibe and in 14% with an add-on PCSK9 inhibitor.
“Fundamental to the recommendations for the new nonstatin therapies to lower cholesterol levels will be an exerted program to increase use of intensive statin therapies as recommended by the current 2013 ACC/AHA cholesterol guidelines,” Sidney C. Smith Jr., MD, of the heart and vascular center at the School of Medicine at University of North Carolina, Chapel Hill, and past president of the American Heart Association and the World Heart Federation, wrote in an accompanying editorial. “Too many patients with [atherosclerotic CVD] do not receive intensive statin therapy as recommended. As noted in the VA study, a nearly 50% reduction in cost or $1 billion savings would be the benefit of optimizing intensive statin therapy and adding ezetimibe for those patients with persisting LDL levels above 70 mg/dL.” – by Cassie Homer
Disclosures: Cannon reports receiving grants from Amgen, Arisaph, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Janssen, Merck and Takeda, and consultant fees from Alnylam, Amarin, Amgen, Arisaph, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Kowa, Merck, Lipimedix, Pfizer, Regeneron Pharmaceuticals, Sanofi and Takeda. Please see the study for all other authors’ relevant financial disclosures. Smith reports no relevant financial disclosures.
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