Q&A: Additional therapies for secondary prevention may be effective, but also expensive
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Results of a 5-year estimate showed that up to 20% of CV events could be prevented if patients with ischemic heart disease or MI received additional secondary prevention therapies that they are eligible for.
However, additional therapies may drive up costs greatly.
According to an analysis published in JAMA Cardiology of 12 recent randomized controlled trials (IMPROVE-IT, PEGASUS, EMPA-REG, LEADER, SUSTAIN-6, FOURIER, CANVAS, REVEAL, CANTOS, COMPASS, ODYSSEY Outcomes and REDUCE-IT), 80% of patients with ischemic heart disease and 99% with MI at baseline were eligible for one or more new medications.
Moreover, of the four drug categories included in the trials (lipid-modifying, antithrombotic, anti-inflammatory and antidiabetic drugs), 41% of patients with ischemic heart disease and 81% with MI were eligible for two or more drug classes simultaneously.
Researchers determined that for each new therapy, patients could experience a 1% to 20% reduction in 5-year CV events.
Healio spoke with study author Børge G. Nordestgaard, MD, DMSc, professor at the University of Copenhagen and chief physician of the department of clinical biochemistry at Copenhagen University Hospital, Denmark, regarding patient access to these potentially expensive therapies as well as strategies for prioritizing their use.
Q: What do these findings add to the current knowledge base on these therapies?
A: Overall, our study illustrates the very positive news that patients with MI and ischemic heart disease now finally have many new drugs available that will reduce their risk for more CVD and even may prolong life. Our head-to-head comparison in the same cohort of 12 novel therapies with respect to eligibility and preventive potential bring novel insight and may help guideline writers better understand how to prioritize between these many options.
Q: What is the clinical significan ce of these findings?
A: Physicians now have many different novel therapeutic options available to lower CVD risk in most patients with ischemic heart disease, that is, on top of statin and aspirin therapy. Thus, physicians have to carefully select the appropriate add-on treatment on a case-by-case basis, taking into account expected efficacy, safety and cost for the individual patient.
Q: With a majority of patients with ischemic heart disease or previous MI being eligible for additional secondary prevention therapies, what are their current barriers to accessing them?
A: The major barriers are limited knowledge among physicians about all these novel therapeutic options, no clear guideline recommendations and high cost for most of them.
Q: What are the underlying mechanisms associated with lack access to these therapies?
A: As long as guidelines do not provide recommendations for many of these novel therapies, including on how to prioritize between them and on whom to select for each type of treatment, they are unlikely to be used on a large scale.
Q: Would the potential cost of multiple therapies impact adherence to medication use?
A: Yes. High cost of prescription drugs has been shown to be one of the most important causes of medication nonadherence. Besides ezetimibe, all other of the novel therapeutic options are still not available in cheap generic versions. Thus, cost is a major issue for their use.
Q: Are these findings conclusive or is there further research planned?
A: Our findings are conclusive for patients with ischemic heart disease and MI, that is, the majority of such patients qualify for novel treatments. However, there are other relevant groups of patients not covered by our study, such as patients with stroke or peripheral artery disease. They may also be candidates for many of the drugs. This needs to be investigated in future studies. – by Scott Buzby
Reference:
Mortensen MB, et al. JAMA Cardiol. 2020;doi:10.1001/jamacardio.2019.4759.
For more information:
Børge G. Nordestgaard, MD, DMSc, can be reached at boerge.nordestgaard@regionh.dk.
Disclosures: Nordestgaard reports he received personal fees from Akcea, Amarin, Amgen, AstraZeneca, Kowa, Novo Nordisk, Regeneron, Sanofi and Silence Therapeutics. Please see the study for all other authors’ relevant financial disclosures.