Determining When to Add Nonstatin Therapy: A Quantitative Approach
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- 作者：Jennifer G. Robinson ; MD ; MPH
- 关键词：cost ; ezetimibe ; nonstatins ; PCSK9 inhibitors ; statins
- 刊名：Journal of the American College of Cardiology
- 出版年：2016
- 出版时间：6 December 2016
- 年：2016
- 卷：68
- 期：22
- 页码：2412-2421
- 全文大小：478 K
- 卷排序：68
文摘
Costs and uncertainty about the benefits of nonstatin therapies limit their use.ObjectivesThe authors sought to identify patients who might benefit from the addition of a nonstatin to background statin therapy.MethodsWe performed systematic reviews of subgroup analyses from randomized trials and observational studies with statin-treated participants to determine estimated 10-year absolute risk of atherosclerotic cardiovascular disease (ASCVD) and to define high-risk and very high-risk patients. We used the relative risk reductions for the addition of a nonstatin to lower low-density lipoprotein (LDL-C) used to determine the number needed to treat (NNT) to prevent 1 ASCVD event over 5 years for each patient group and to allow comparisons with 5-year cost analyses.ResultsThe 10-year ASCVD risk is at least 30% (very high risk) for statin-treated participants with clinical ASCVD and comorbidities, and 20% to 29% (high risk) for those with ASCVD without comorbidities or who have heterozygous familial hypercholesterolemia. Adding ezetimibe to reduce low-density LDL-C by 20% would provide a 5-year NNT ≤50 for very high-risk patients with LDL-C ≥130 mg/dl or for high-risk patients with LDL-C ≥190 mg/dl, and an NNT ≤30 for very high-risk patients with LDL-C ≥160 mg/dl. Adding a PCSK9 monoclonal antibody to lower LDL-C by at least 50% would provide an NNT ≤50 for very high-risk and high-risk patients with LDL-C ≥70 mg/dl, and an NNT ≤30 for very high-risk and high-risk patients with an LDL-C ≥130 mg/dl.ConclusionsAdding ezetimibe or PCSK9 monoclonal antibodies to maximally tolerated statin therapy may be cost effective in very high-risk and high-risk patients, depending on baseline LDL-C levels.