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Revankar S, Park JK, Satish P, Agarwala A. Is there a role for earlier use of combination therapy? Am J Prev Cardiol 2024; 17:100639. [PMID: 38419948 PMCID: PMC10900258 DOI: 10.1016/j.ajpc.2024.100639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/02/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
As the global population ages and cardiovascular risk factors rise, we can expect a continued increase in atherosclerotic disease. Low-density lipoprotein cholesterol (LDL-C) reduction is a cornerstone of cardiovascular risk reduction with strong, causal evidence indicating that the greatest benefit is derived from early and large decreases in LDL-C. Despite the adoption of statins as the backbone of lipid-therapy regimens, numerous studies and registry analyses reveal our collective inability to achieve LDL-C goals in high-risk patients. Combination therapy with ezetimibe has been shown to result in statistically significant decreases in LDL-C level, atheroma volume, and cardiovascular adverse event rates. A major barrier to implementing an upfront combination therapy approach is the perceived side effects from therapeutic agents although multiple studies show that a therapeutic patient-physician relationship could overcome this issue. Novel agents such as PCSK-9 inhibitors, bempedoic acid, and inclisiran have the potential to achieve similar outcomes although additional research is needed regarding the cost effectiveness of these approaches. Despite these hurdles, there is a role for the newer agents early in the disease course of high-risk patients such as those with markedly elevated LDL-C >190 mg/dL and FH. The implementation of upfront combination therapy, especially in high-risk patients, will decrease clinical inertia while allowing for earlier consideration of newer, effective agents to decrease cardiovascular burden.
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Affiliation(s)
- Shruti Revankar
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jong Kun Park
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Priyanka Satish
- The University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, TX, USA
| | - Anandita Agarwala
- Center for Cardiovascular Disease Prevention, Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX, USA
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Raschi E, Casula M, Cicero AFG, Corsini A, Borghi C, Catapano A. Beyond statins: New pharmacological targets to decrease LDL-cholesterol and cardiovascular events. Pharmacol Ther 2023; 250:108507. [PMID: 37567512 DOI: 10.1016/j.pharmthera.2023.108507] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023]
Abstract
The pharmacological treatment of dyslipidemia, a major modifiable risk factor for developing atherosclerotic cardiovascular disease (ASCVD), remains a debated and controversial issue, not only in terms of the most appropriate therapeutic range for lipid levels, but also with regard to the optimal strategy and sequence approach (stepwise vs upstream therapy). Current treatment guidelines for the management of dyslipidemia focus on the intensity of low-density lipoprotein cholesterol (LDL-C) reduction, stratified according to risk for developing ASCVD. Beyond statins and ezetimibe, different medications targeting LDL-C have been recently approved by regulatory agencies with potential innovative mechanisms of action, including proprotein convertase subtilisin/kexin type 9 modulators (monoclonal antibodies such as evolocumab and alirocumab; small interfering RNA molecules such as inclisiran), ATP-citrate lyase inhibitors (bempedoic acid), angiopoietin-like 3 inhibitors (evinacumab), and microsomal triglyceride transfer protein inhibitors (lomitapide). An understanding of their pharmacological aspects, benefit-risk profile, including impact on hard cardiovascular endpoints beyond LDL-C reduction, and potential advantages from the patient perspective (e.g., adherence) - the focus of this evidence-based review - is crucial for practitioners across medical specialties to minimize therapeutic inertia and support clinical practice.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
| | - Manuela Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy; IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Arrigo F G Cicero
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
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3
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Sakhuja S, Bittner VA, Brown TM, Farkouh ME, Levitan EB, Safford MM, Woodward M, Chen L, Sun R, Dhalwani N, Jones J, Kalich B, Exter J, Muntner P, Rosenson RS, Colantonio LD. Recurrent Atherosclerotic Cardiovascular Disease Events Potentially Prevented with Guideline-Recommended Cholesterol-Lowering Therapy following Myocardial Infarction. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07452-1. [PMID: 37052867 DOI: 10.1007/s10557-023-07452-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE Many adults with atherosclerotic cardiovascular disease (ASCVD) who are recommended to take a statin, ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) by the 2018 American Heart Association/American College of Cardiology cholesterol guideline do not receive these medications. We estimated the percentage of recurrent ASCVD events potentially prevented with guideline-recommended cholesterol-lowering therapy following a myocardial infarction (MI) hospitalization. METHODS We conducted simulations using data from US adults with government health insurance through Medicare or commercial health insurance in the MarketScan database. We used data from patients with an MI hospitalization in 2018-2019 to estimate the percentage receiving guideline-recommended therapy. We used data from patients with an MI hospitalization in 2013-2016 to estimate the 3-year cumulative incidence of recurrent ASCVD events (i.e., MI, coronary revascularization or ischemic stroke). The low-density lipoprotein cholesterol (LDL-C) reduction with guideline-recommended therapy was derived from trials of statins, ezetimibe and PCSK9i, and the associated ASCVD risk reduction was estimated from a meta-analysis by the Cholesterol-Lowering Treatment Trialists Collaboration. RESULTS Among 279,395 patients with an MI hospitalization in 2018-2019 (mean age 75 years, mean LDL-C 92 mg/dL), 27.3% were receiving guideline-recommended cholesterol-lowering therapy. With current cholesterol-lowering therapy use, 25.3% (95%CI: 25.2%-25.4%) of patients had an ASCVD event over 3 years. If all patients were to receive guideline-recommended therapy, 19.8% (95%CI: 19.5%-19.9%) were estimated to have an ASCVD event over 3 years, representing a 21.6% (95%CI: 20.5%-23.6%) relative risk reduction. CONCLUSION Implementation of guideline-recommended cholesterol-lowering therapy could prevent a substantial percentage of recurrent ASCVD events.
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Affiliation(s)
- Swati Sakhuja
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Vera A Bittner
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Todd M Brown
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto and Heart and Stroke Richard Lewar Centre of Excellence, Toronto, ON, Canada
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, School of Public Health, Imperial College, London, UK
| | - Ligong Chen
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ruoyan Sun
- Department of Healthcare Policy and Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nafeesa Dhalwani
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - Jenna Jones
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | | | | | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert S Rosenson
- Icahn School of Medicine at Mount Sinai, Mount Sinai Heart, New York, NY, USA
| | - Lisandro D Colantonio
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
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4
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McKinley EC, Bittner VA, Brown TM, Chen L, Exter J, Farkouh ME, Huang L, Jackson EA, Levitan EB, Orroth KK, Reading SR, Rosenson RS, Safford MM, Woodward M, Muntner P, Colantonio LD. The Projected Impact of Population-Wide Achievement of LDL Cholesterol <70 mg/dL on the Number of Recurrent Events Among US Adults with ASCVD. Cardiovasc Drugs Ther 2023; 37:107-116. [PMID: 34599698 DOI: 10.1007/s10557-021-07268-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 01/14/2023]
Abstract
PURPOSE Adults with atherosclerotic cardiovascular disease (ASCVD) are recommended high-intensity statins, with those at very high risk for recurrent events recommended adding ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor if their low-density lipoprotein cholesterol (LDL-C) is ≥70 mg/dL. We estimated the number of recurrent ASCVD events potentially averted if all adults in the United States (US) ≥45 years of age with ASCVD achieved an LDL-C <70 mg/dL. METHODS The number of US adults with ASCVD and LDL-C ≥70 mg/dL was estimated from the National Health and Nutrition Examination Survey 2009-2016 (n = 596). The 10-year cumulative incidence of recurrent ASCVD events was estimated from the REasons for Geographic And Racial Differences in Stroke study (n = 5390), weighted to the US population by age, race, and sex. The ASCVD risk reduction by achieving an LDL-C <70 mg/dL was estimated from meta-analyses of lipid-lowering treatment trials. RESULTS Overall, 14.7 (95% CI, 13.7-15.8) million US adults had ASCVD, of whom 11.6 (95% CI, 10.6-12.5) million had LDL-C ≥70 mg/dL. The 10-year cumulative incidence of ASCVD events was 24.3% (95% CI, 23.2-25.6%). We projected that 2.823 (95% CI, 2.543-3.091) million ASCVD events would occur over 10 years among US adults with ASCVD and LDL-C ≥70 mg/dL. Overall, 0.634 (95% CI, 0.542-0.737) million ASCVD events could potentially be averted if all US adults with ASCVD achieved and maintained LDL-C <70 mg/dL. CONCLUSION A substantial number of recurrent ASCVD events could be averted over 10 years if all US adults with ASCVD achieved, and maintained, an LDL-C <70 mg/dL.
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Affiliation(s)
- Emily C McKinley
- Department of Epidemiology, University of Alabama at Birmingham, 1665 University Blvd, RPHB 523B, Birmingham, AL, 35233-0013, USA.
| | - Vera A Bittner
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Todd M Brown
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ligong Chen
- Department of Epidemiology, University of Alabama at Birmingham, 1665 University Blvd, RPHB 523B, Birmingham, AL, 35233-0013, USA
| | | | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto and Heart and Stroke Richard Lewar Centre of Excellence, Toronto, ON, Canada
| | - Lei Huang
- Department of Epidemiology, University of Alabama at Birmingham, 1665 University Blvd, RPHB 523B, Birmingham, AL, 35233-0013, USA
| | - Elizabeth A Jackson
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, 1665 University Blvd, RPHB 523B, Birmingham, AL, 35233-0013, USA
| | - Kate K Orroth
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | | | - Robert S Rosenson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, 1665 University Blvd, RPHB 523B, Birmingham, AL, 35233-0013, USA
| | - Lisandro D Colantonio
- Department of Epidemiology, University of Alabama at Birmingham, 1665 University Blvd, RPHB 523B, Birmingham, AL, 35233-0013, USA
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5
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Alanaeme CJ, Bittner V, Brown TM, Colantonio LD, Dhalwani N, Jones J, Kalich B, Exter J, Jackson EA, Levitan EB, Poudel B, Wang Z, Woodward M, Muntner P, Rosenson RS. Estimated number and percentage of US adults with atherosclerotic cardiovascular disease recommended add-on lipid-lowering therapy by the 2018 AHA/ACC multi-society cholesterol guideline. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 21:100201. [PMID: 37168932 PMCID: PMC10168648 DOI: 10.1016/j.ahjo.2022.100201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Study objective The 2018 American Heart Association/American College of Cardiology (AHA/ACC) cholesterol guideline recommends a maximally-tolerated statin with add-on lipid-lowering therapy, ezetimibe and/or proprotein convertase subtilisin/kexin type 9 (PCSK9) for adults with very-high atherosclerotic cardiovascular disease (ASCVD) risk to achieve a low-density lipoprotein cholesterol (LDL-C) <70 mg/dL. We estimated the percentage of US adults with ASCVD recommended, by the 2018 AHA/ACC cholesterol guideline, and receiving add-on lipid-lowering therapy. Design setting and participants Cross-sectional study including 805 participants from the US National Health and Nutrition Examination Survey (NHANES) 2013-2020 data. NHANES sampling weights were used to obtain estimates for the US adult population. Main measures Very-high ASCVD risk was defined as either: ≥2 ASCVD events, or one ASCVD event with ≥2 high-risk conditions. Being recommended add-on lipid-lowering therapy was defined as having very-high ASCVD risk and LDL-C ≥ 70 mg/dL, or LDL-C < 70 mg/dL while taking ezetimibe or a PCSK9 inhibitor. Results An estimated 18.7 (95%CI, 16.0-21.4) million US adults had ASCVD, of whom 81.6 % (95%CI, 76.7 %-86.4 %) had very-high ASCVD risk, and 60.1 % (95%CI, 54.5 %-65.7 %) had very-high ASCVD risk and LDL-C ≥ 70 mg/dL. Overall, 61.4 % (95%CI, 55.8 %-66.9 %) were recommended add-on lipid-lowering therapy and 3.2 % (95 % CI, 1.2 %-5.3 %) were taking it. Smokers, adults with diabetes, hypertension and chronic kidney disease were more likely, while those taking atorvastatin or rosuvastatin were less likely, to be recommended add-on lipid-lowering therapy. Conclusion The majority of US adults with ASCVD are recommended add-on lipid-lowering therapy by the 2018 AHA/ACC cholesterol guideline but few are receiving it.
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Affiliation(s)
- Chibuike J. Alanaeme
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
- Corresponding author at: The University of Alabama at Birmingham – UABSchool of Public Health, Department of Epidemiology, 527A, USA. (C.J. Alanaeme)
| | - Vera Bittner
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Todd M. Brown
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Nafeesa Dhalwani
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - Jenna Jones
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | | | | | - Elizabeth A. Jackson
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bharat Poudel
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zhixin Wang
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark Woodward
- The George Institute for Global Health, Imperial College London, UK
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert S. Rosenson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Underberg J, Toth PP, Rodriguez F. LDL-C target attainment in secondary prevention of ASCVD in the United States: barriers, consequences of nonachievement, and strategies to reach goals. Postgrad Med 2022; 134:752-762. [PMID: 36004573 DOI: 10.1080/00325481.2022.2117498] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in the United States. Elevated low-density lipoprotein cholesterol (LDL-C) is a major causal risk factor for ASCVD. Current evidence overwhelmingly demonstrates that lowering LDL-C reduces the risk of secondary cardiovascular events in patients with previous myocardial infarction or stroke. There is no lower limit for LDL-C: large, randomized studies and meta-analyses have found continuous benefit and no safety concerns in patients achieving LDL-C levels <25 mg/dL. As 'Time is plaque' in patients with ASCVD, early, sustained reductions in LDL-C are critical to slow or halt disease progression. However, despite use of lipid-lowering medications, <30% of patients with ASCVD achieve guideline-recommended reductions in LDL-C, resulting in a substantial societal burden of preventable cardiovascular events and early mortality. LDL-C goals are not met due to several factors: lipid-lowering therapy is not initiated and intensified as directed by clinical guidelines (clinical inertia); most patients do not adhere to prescribed medications; and high-risk patients are frequently denied access to add-on therapies by their insurance providers. Promoting patient and clinician education, multidisciplinary collaboration, and other interventions may help to overcome these barriers. Ultimately, achieving population-level guideline-recommended reductions in LDL-C will require a collaborative effort from patients, clinicians, relevant professional societies, drug manufacturers, and payers.
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Affiliation(s)
| | - Peter P Toth
- Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
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Maitra NS, Mahtta D, Navaneethan S, Vaughan EM, Kochar A, Gulati M, Levine GN, Petersen LA, Virani SS. A Mistake Not to Be Repeated: What Can We Learn from the Underutilization of Statin Therapy for Efficient Dissemination of Cardioprotective Glucose Lowering Agents? Curr Cardiol Rep 2022; 24:689-698. [PMID: 35352278 DOI: 10.1007/s11886-022-01694-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To review the factors contributing to underutilization of guideline-directed therapies, identify strategies to alleviate these factors, and apply these strategies for effective and timely dissemination of novel cardioprotective glucose-lowering agents. RECENT FINDINGS Recent analyses demonstrate underutilization of cardioprotective glucose lowering agents despite guideline recommendations for their use. Major contributors to underutilization of guideline-directed therapies include therapeutic inertia, perceptions about side effects, and factors found at the level of the clinicians, patients, and the healthcare system. The recent emergence of several novel therapies, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, for use in cardiovascular disease provides a unique avenue to improve patient outcomes. To effectively utilize novel cardioprotective glucose lowering agents to improve cardiovascular outcomes, clinicians must recognize and learn from prior barriers to application of guideline-directed therapies. Further endeavors are prudent to ensure uptake of novel agents.
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Affiliation(s)
- Neil S Maitra
- Division of General Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Dhruv Mahtta
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA
| | - Sankar Navaneethan
- Section of Nephrology and Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
- Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Elizabeth M Vaughan
- Division of General Internal Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ajar Kochar
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Martha Gulati
- Section of Cardiology, University of Arizona College of Medicine - Phoenix, Phoenix, AR, USA
| | - Glenn N Levine
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA
- Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Salim S Virani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA.
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
- Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development, 2002 Holcombe Boulevard, Houston, TX, USA.
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8
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Susekov AV. Topical issues concerning modern lipid-lowering therapy. CONSILIUM MEDICUM 2022. [DOI: 10.26442/20751753.2022.1.201484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Hypercholesterolemia (high levels of atherogenic lipoproteins) is the main modifiable cardiovascular risk factor in most of the populations, including the Russian population. 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) have been used in clinical practice for more than 40 years and have a substantial evidence-based proof of efficacy and safety. Unfortunately, the most of the patients with high cardiovascular risk, including the Russian Federation, still receive initial statin doses and only in 10% of the cases we can reach the recommended target level of low-density lipoprotein cholesterol. This article deals with the current principles of statin therapy according to the latest guidelines and shows updated information concerning the optimization of statin therapy in the elderly and in patients with chronic kidney disease. This article, as well, shows the safety of applying HMG-CoA reductase inhibitors (impact on muscles, liver and cognitive impairments). In addition, the review presents the algorithms for the combination therapy of statins and ezetimibe.
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9
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McKinley EC, Bittner VA, Brown TM, Chen L, Colantonio LD, Exter J, Orroth KK, Reading SR, Rosenson RS, Muntner P. Factors associated with time to initiation of a PCSK9 inhibitor after hospital discharge for acute myocardial infarction. J Clin Lipidol 2021; 16:75-82. [PMID: 34848176 DOI: 10.1016/j.jacl.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) lower atherosclerotic cardiovascular disease (ASCVD) event risk. OBJECTIVE Analyze patient characteristics associated with time to PCSK9i initiation following an acute myocardial infarction (AMI). METHODS We analyzed characteristics of patients ≥21 years of age in the Marketscan or Medicare databases who initiated a PCSK9i 0-89 days, 90-179 days, or 180-365 days after an AMI between July 2015 and December 2018 (n=1,705). We estimated the cumulative incidence of recurrent ASCVD events before PCSK9i initiation. RESULTS Overall, 42%, 25%, and 33% of patients who initiated a PCSK9i did so 0-89 days, 90-179 days, and 180-365 days following AMI hospital discharge, respectively. Taking ezetimibe prior to AMI hospitalization and initiating ezetimibe within 30 days after AMI hospital discharge were each associated with a higher likelihood of PCSK9i initiation in the 0-89 days versus 180-365 days post-discharge (adjusted odds ratio [OR] 1.83, 95% confidence interval [95%CI] 1.35-2.49 and 1.76, 95%CI 1.11-2.80, respectively). Statin use before and statin initiation within 30 days after AMI hospitalization were associated with a lower likelihood of PCSK9i initiation 0-89 days versus 180-365 days post-discharge (adjusted OR 0.64, 95%CI 0.49-0.84 and 0.39, 95%CI 0.28-0.54, respectively). Overall, 8.0%, 10.5%, and 12.5% of patients had an ASCVD event at 90, 180, and 365 days following AMI hospital discharge and before initiating a PCSK9i, respectively. CONCLUSION Among patients initiating a PCSK9i after AMI, a low proportion did so within 89 days of hospital discharge. Many patients had a recurrent ASCVD event before treatment initiation.
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Affiliation(s)
- E C McKinley
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham AL, United States.
| | - V A Bittner
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham AL, United States.
| | - T M Brown
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham AL, United States.
| | - L Chen
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham AL, United States.
| | - L D Colantonio
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham AL, United States.
| | - J Exter
- Amgen Inc., Thousand Oaks CA, United States.
| | - K K Orroth
- Center for Observational Research, Amgen Inc., Thousand Oaks CA, United States.
| | - S R Reading
- Center for Observational Research, Amgen Inc., Thousand Oaks CA, United States.
| | - R S Rosenson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York NY, United States.
| | - P Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham AL, United States.
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10
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Trends in PCSK9 Inhibitor Prescriptions before and after the Price Reduction in Patients with Atherosclerotic Cardiovascular Disease. J Clin Med 2021; 10:jcm10173828. [PMID: 34501275 PMCID: PMC8432238 DOI: 10.3390/jcm10173828] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 07/23/2021] [Accepted: 08/23/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors reduce low-density lipoprotein (LDL) cholesterol and cardiovascular event rates, yet due to their high price remain underutilized and difficult to prescribe in clinical practice. In March 2018, their price was significantly reduced. We evaluated whether the price reduction would improve prescribing patterns of PCSK9 inhibitors in eligible patients with atherosclerotic cardiovascular disease (ASCVD). METHODS We identified the number of eligible ASCVD patients and those prescribed a PCSK9 inhibitor for each year between July 2015 and December 2019. Patient demographics and clinical characteristics for those prescribed a PCSK9 inhibitor were extracted from their electronic health record. RESULTS In total 1059 patients of eligible patients received a new prescription for a PCSK9 inhibitor. From 2015 to 2019, the rate of new prescriptions among eligible patients increased from 0.5 to 3.3% (p < 0.001) and continuation rates increased from 18 to 60% (p < 0.001). Following the price reduction, patients who were prescribed a PCSK9 inhibitor were younger and more likely to be female, but less likely to have Medicare insurance. CONCLUSIONS Despite the reduction in the cost of PCSK9 inhibitors, most eligible patients are not prescribed one. The reduction in cost has improved adherence, primarily in patients with commercial insurance. Older patients and those on Medicare still face significant barriers in accessing a PCSK9 inhibitor. Further reductions in the price of the PCSK9 inhibitors are needed as is further study of the barriers that exist in prescribing one.
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di Mauro G, Zinzi A, Scavone C, Mascolo A, Gaio M, Sportiello L, Ferrajolo C, Rafaniello C, Rossi F, Capuano A. PCSK9 Inhibitors and Neurocognitive Adverse Drug Reactions: Analysis of Individual Case Safety Reports from the Eudravigilance Database. Drug Saf 2020; 44:337-349. [PMID: 33351170 PMCID: PMC7892743 DOI: 10.1007/s40264-020-01021-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 02/07/2023]
Abstract
Introduction Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9Is) were associated with a risk of neurocognitive adverse drug reactions (ADRs). Objective We aimed to investigate the occurrence of neuropsychiatric ADRs related to PCSK9Is. Methods We analyzed Individual Case Safety Reports (ICSRs) sent through the European pharmacovigilance database that reported alirocumab or evolocumab as the suspected drug and at least one neurological or psychiatric ADR. The reporting odds ratio (ROR) was computed to compare the probability of reporting ICSRs with neuropsychiatric ADRs between alirocumab, evolocumab and statins. Results Overall, 2041 ICSRs with alirocumab and/or evolocumab as the suspected drug described the occurrence of neuropsychiatric ADRs. The most reported preferred terms for both drugs were headache, insomnia and depression. No difference between alirocumab and evolocumab was observed for the RORs of ICSRs with ADRs belonging to the System Organ Classes (SOCs) ‘Nervous system disorders’ or ‘Psychiatric disorders’ (ROR 1.02, 95% confidence interval 0.91–1.14; and 1.12, 95% CI 0.94–1.34, respectively), while evolocumab and alirocumab had a higher reporting probability of ICSRs with ADRs belonging to the SOC ‘Nervous system disorders’ compared with atorvastatin and fluvastatin. A lower reporting probability was instead found for ICSRs with ADRs belonging to the SOC ‘Psychiatric disorders’ for evolocumab and alirocumab versus simvastatin, pravastatin and rosuvastatin. Conclusion Our results demonstrated that 22.7% of all ICSRs reporting alirocumab or evolocumab as suspect drugs described the occurrence of neuropsychiatric ADRs. The ROR showed that evolocumab and alirocumab had a higher reporting probability of neurological ADRs compared with statins. Further data from real-life contexts are needed. Electronic supplementary material The online version of this article (10.1007/s40264-020-01021-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gabriella di Mauro
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.,Regional Centre for Pharmacovigilance, Campania Region, Naples, Italy
| | - Alessia Zinzi
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.,Regional Centre for Pharmacovigilance, Campania Region, Naples, Italy
| | - Cristina Scavone
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy. .,Regional Centre for Pharmacovigilance, Campania Region, Naples, Italy.
| | - Annamaria Mascolo
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.,Regional Centre for Pharmacovigilance, Campania Region, Naples, Italy
| | - Mario Gaio
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.,Regional Centre for Pharmacovigilance, Campania Region, Naples, Italy
| | - Liberata Sportiello
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.,Regional Centre for Pharmacovigilance, Campania Region, Naples, Italy
| | - Carmen Ferrajolo
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.,Regional Centre for Pharmacovigilance, Campania Region, Naples, Italy
| | - Concetta Rafaniello
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.,Regional Centre for Pharmacovigilance, Campania Region, Naples, Italy
| | - Francesco Rossi
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.,Regional Centre for Pharmacovigilance, Campania Region, Naples, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.,Regional Centre for Pharmacovigilance, Campania Region, Naples, Italy
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12
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Zafrir B, Egbaria A, Stein N, Elis A, Saliba W. PCSK9 inhibition in clinical practice: Treatment patterns and attainment of lipid goals in a large health maintenance organization. J Clin Lipidol 2020; 15:202-211.e2. [PMID: 33243717 DOI: 10.1016/j.jacl.2020.11.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/30/2020] [Accepted: 11/09/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type-9 inhibitors (PCSK9i) effectively reduce low-density lipoprotein cholesterol (LDL-C), improving cardiovascular outcomes in clinical trials when added to statin therapy. OBJECTIVES As real-world evidence is lacking, we aimed to evaluate treatment and adherence patterns using PCSK9i in clinical practice. METHODS We investigated 1600 patients initiating PCSK9i between January 2016 and December 2019 in a large health maintenance organization. Treatment discontinuation was defined as a gap ≥60 days between last days' supply of one prescription and the start of the next. Re-initiation rates as well as proportion of days covered (PDC) over 1-year period and attainment of lipid goals under PCSK9i, were analyzed. RESULTS Evolocumab 140 mg was initiated by 50.7%, alirocumab 75 mg by 29.5% and 150 mg by 19.8%. Cumulative discontinuation rates were 28.1% after 6-months and 49.9% after 3-years. Overall, 58% of the patients that discontinued therapy have re-initiated PCSK9i (31% after 3-months from discontinuation). Mean PDC over 1-year of therapy was 56% ± 29, with PDC ≥80% evident in 29%. Of those with established cardiovascular disease (n = 991), 55% achieved LDL-C<70 mg/dL and 38% LDL-C<55 mg/dL. Attainment rates were lower in patients with PDC<80%, baseline LDL-C>190 mg/dL and in those not treated with concurrent statin therapy. CONCLUSIONS In real-world practice of patients treated by PCSK9i, high proportion of early treatment discontinuation was evident, with non-negligible re-initiation rates but overall low medication coverage over time. This have contributed to sub-optimal attainment of LDL-C treatment goals, particularly observed in patients with severe hypercholesterolemia, inadequate drug adherence, and those using PCSK9i as monotherapy.
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Affiliation(s)
- Barak Zafrir
- The Department of Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel; The Faculty of Medicine, Technion, Israel Institute of Medicine, Haifa, Israel.
| | - Aya Egbaria
- The Faculty of Medicine, Technion, Israel Institute of Medicine, Haifa, Israel
| | - Nili Stein
- The Statistical Unit, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Avishay Elis
- The Department of Medicine, Beilinson Hospital, Rabin Medical Center, PetachTikva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Walid Saliba
- The Faculty of Medicine, Technion, Israel Institute of Medicine, Haifa, Israel; The Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Haifa, Israel
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13
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Singh C, Valero DJ, Nisar J, Trujillo Ramirez JI, Kothari KK, Isola S, San Hernandez AM, Gordon DK. Statins Versus Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors- Are We Doing Better? A Systematic Review on Treatment Disparity. Cureus 2020; 12:e10965. [PMID: 33209524 PMCID: PMC7667606 DOI: 10.7759/cureus.10965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Coronary artery disease (CAD) is a significant contributor to mortality in America. A common risk factor of CAD is hyperlipidemia. Treatment guidelines of hyperlipidemia are well established. Statins are the cornerstone of treating hyperlipidemia. New medications such as proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9 inhibitors) have also illustrated significant results in treating hyperlipidemia. While multiple studies exemplify the disparities in statin and PCSK9 inhibitors utilization to reduce CAD mortality and risk factors, there are no systematic reviews to validate these disparities. We conducted a search on PubMed, including Medline and PubMed Central, and Google Scholar. For this analysis, we selected articles published between 2000 and 2020 and those that fit the inclusion and exclusion criteria. Based on the type of study, we performed appropriate quality assessments and deleted studies with a score of less than seven or with a high risk of biases. The search strategy resulted in 322 studies. After inclusion and exclusion criteria were applied, we included 20 articles in the analysis of this review. This systematic review demonstrates that non-white races and women were less likely to receive the correct, clinically indicated, therapy for hyperlipidemia. A multi-faceted approach is required to solve this inequality in healthcare.
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Affiliation(s)
- Chetana Singh
- Primary Care, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Danel J Valero
- Anesthesia, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Javariya Nisar
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jose I Trujillo Ramirez
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Karisma K Kothari
- Medicine, Xavier University School of Medicine, Oranjestad, ABW.,Primary Care, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sasank Isola
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Aleyda M San Hernandez
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Domonick K Gordon
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Internal Medicine, Scarborough General Hospital, Scarborough, TTO
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14
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Ross EL, Soeteman DI. Cost-Effectiveness of Esketamine Nasal Spray for Patients With Treatment-Resistant Depression in the United States. Psychiatr Serv 2020; 71:988-997. [PMID: 32631129 PMCID: PMC7920520 DOI: 10.1176/appi.ps.201900625] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This study aimed to estimate the cost-effectiveness of esketamine, a novel intranasally dosed antidepressant, for patients in the United States with treatment-resistant depression. METHODS A decision-analytic model parameterized with efficacy data from phase 3 randomized trials of esketamine was used to simulate the effects of treatment with esketamine versus oral antidepressants over a 5-year horizon, from both societal and health care sector perspectives. Outcomes included remission and response of depression, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs) for esketamine. Value-based prices were calculated, defined as the per-dose price at which esketamine would become cost-effective given cost-effectiveness thresholds of $50,000/QALY, $100,000/QALY, and $150,000/QALY. Uncertainty in these outcomes was assessed with probabilistic sensitivity analyses. Key model parameters included the efficacy of esketamine versus oral antidepressants (relative risk of 1.39 for remission; 1.32 for response) and the monthly cost of esketamine ($5,572 for month 1; $1,699-$2,244 thereafter). RESULTS Over 5 years, esketamine was projected to increase time in remission from 25.3% to 31.1% of life-years, resulting in a gain of 0.07 QALYs. Esketamine increased societal costs by $16,617 and health care sector costs by $16,995. Base case ICERs were $237,111/QALY (societal) and $242,496/QALY (health care sector). Probabilistic sensitivity analysis showed a greater than 95% likelihood that esketamine's ICER would be above $150,000/QALY. At a cost-effectiveness threshold of $150,000/QALY, esketamine's value-based price was approximately $140/dose (versus a current price of $240/dose). CONCLUSIONS Esketamine is unlikely to be cost-effective for management of treatment-resistant depression in the United States unless its price falls by more than 40%.
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Affiliation(s)
- Eric L Ross
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts (Ross); Department of Psychiatry, Massachusetts General Hospital (Ross), Department of Psychiatry, Harvard Medical School (Ross), and Center for Health Decision Science, Harvard T. H. Chan School of Public Health, all in Boston (Soeteman)
| | - Djøra I Soeteman
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts (Ross); Department of Psychiatry, Massachusetts General Hospital (Ross), Department of Psychiatry, Harvard Medical School (Ross), and Center for Health Decision Science, Harvard T. H. Chan School of Public Health, all in Boston (Soeteman)
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15
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Karalis DG. Editorial commentary: Advances in the management of dyslipidemia: The future is bright, but what we do today is what matters most. Trends Cardiovasc Med 2020; 31:425-426. [PMID: 32898691 DOI: 10.1016/j.tcm.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 08/30/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Dean G Karalis
- Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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16
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Chen K, Canfield S, Blackwell J, Houmes S, Jones S, Lindsley J. Optimization of Lipid-Lowering Therapy for High Cardiovascular Risk Patients Through Electronic Medical Record Reporting and Pharmacist Evaluation. J Manag Care Spec Pharm 2020; 26:1010-1016. [PMID: 32715962 PMCID: PMC10391165 DOI: 10.18553/jmcp.2020.26.8.1010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Identification of high cardiovascular risk patients on suboptimal lipid-lowering therapy (LLT) may be possible through electronic medical record (EMR) reporting, presenting an opportunity for pharmacist involvement in optimizing drug regimens. OBJECTIVES To (a) identify high cardiovascular risk patients with opportunities for LLT optimization through EMR reporting and (b) evaluate effectiveness of pharmacist review and treatment algorithm on recommending treatment modifications compared with algorithm application alone. METHODS We generated an EMR report to identify adult patients aged 21-75 years with clinical atherosclerotic cardiovascular disease and low-density lipoprotein cholesterol (LDL-C) level ≥ 70 mg/dL during a 6-month period and collected pertinent data elements. We selected a subgroup of patients for remote pharmacist review and determined recommendations based on our predefined LLT optimization algorithm and pharmacist clinical judgment. One pharmacist was responsible for making all recommendations and communicated potential treatment modification to primary care providers via email and/or EMR messaging. We tracked provider acceptable/rejection rate to all recommendations made. We also compared recommendations based on using the algorithm alone to combining pharmacist chart review and algorithm and examined reasons for any discrepancies. RESULTS 941 patients met inclusion criteria, with 399 patients (42.4%) not currently on any LLT. At baseline, 249 patients (25.3%) were on a high-intensity statin, and 19 (1.9%) were on a proprotein convertase subtilisin/kexin type 9 inhibitor. A subgroup of 34 patients were reviewed, of which 30 (88.2%) were on suboptimal therapy despite not achieving LDL-C goals. The pharmacist recommended to intensify statin therapy for 16 patients (47.1%), initiate nonstatin therapy for 9 patients (26.5%), and initiate statin therapy in 5 patients (14.7%). Pharmacist recommendation acceptance rate was 53.3%, with no response received in 26.6% of cases. The algorithm evaluation alone yielded the same recommendation as the combined pharmacist review with algorithm in 30 (88.2%) of the cases and differed in 4 cases. CONCLUSIONS The underutilization of LLT among high cardiovascular risk patients remains a growing issue despite effective treatment options with cardiovascular benefits. Pharmacists may be able to identify these patients by using reportable EMR data elements and applying a treatment optimization algorithm to make therapy recommendations and improve outcomes. DISCLOSURES This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no relevant declarations of interest to disclose. This study was presented as a poster presentation at the APhA Annual Meeting, March 2019, Seattle, WA, and as a platform presentation at the Eastern States Conference, May 2019, Hershey, PA.
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Affiliation(s)
- Kaylee Chen
- Johns Hopkins Home Care Group, Baltimore, Maryland
| | | | | | | | - Steven Jones
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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17
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Patient Characteristics and Treatment Patterns among Medicare Beneficiaries Initiating PCSK9 Inhibitor Therapy. Cardiovasc Drugs Ther 2020; 35:965-973. [PMID: 32594283 DOI: 10.1007/s10557-020-07028-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE There is limited real-world evidence around use of proprotein convertase subtilisin-kexin type 9 inhibitors (PCSK9i) among US older adults. This study examined baseline characteristics of fee-for-service (FFS) Medicare beneficiaries newly initiating PCSK9i therapy during the period immediately following market availability. METHODS This cross-sectional study used Medicare claims (2013-2016) to identify 5051 FFS Medicare beneficiaries who filled ≥ 1 PCSK9i prescription between August 2015 and December 2016. We analyzed patient demographics, clinical characteristics, and baseline healthcare expenditures in the 12-month period prior to PCSK9i initiation, for these beneficiaries. RESULTS Most beneficiaries initiating PCSK9i were female (57%), < 75 years of age (61%), white (89%), and lived in metropolitan areas (83%). At baseline, these PCSK9i initiators had 6 chronic conditions on average, with conditions such as hyperlipidemia, hypertension, and ischemic heart disease being most prevalent. Approximately 88% had a diagnosis of atherosclerotic cardiovascular disease (ASCVD), and 14% experienced acute cardiovascular events during the 12-month baseline period. Use of any statin and/or ezetimibe ranged from 54 to 76% in the 6-month and 24-month baseline period. Their total annual Medicare expenditures averaged US$17,552, of which most were attributable to ambulatory care and prescription use, in the 12-month baseline period. CONCLUSION High burden of cardiovascular conditions and prescription expenditures at baseline were common among FFS beneficiaries initiating PCSK9i therapy. These findings suggest that physicians prescribe PCSK9i to elderly patients at high risk for adverse cardiovascular events. Considering the evolving treatment landscape, PCSK9i utilization might increase in Medicare.
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18
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Scirica BM, Bergmark BA, Morrow DA, Antman EM, Bonaca MP, Murphy SA, Sabatine MS, Braunwald E, Wiviott SD. Nonculprit Lesion Myocardial Infarction Following Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome. J Am Coll Cardiol 2020; 75:1095-1106. [DOI: 10.1016/j.jacc.2019.12.067] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/22/2019] [Accepted: 12/23/2019] [Indexed: 12/12/2022]
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19
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Nanna MG, Peterson ED. Translating the Secondary Prevention Therapeutic Boom Into Action. JAMA Cardiol 2020; 5:215-216. [PMID: 31895445 DOI: 10.1001/jamacardio.2019.4959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Michael G Nanna
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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20
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PCSK9 Inhibitors’ New Users: Analysis of Prescription Patterns and Patients’ Characteristics from an Italian Real-world Study. Clin Drug Investig 2019; 40:173-181. [DOI: 10.1007/s40261-019-00877-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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21
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Affiliation(s)
- Haitham M Ahmed
- From the Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | - Steven E Nissen
- From the Department of Cardiovascular Medicine, Cleveland Clinic, OH
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22
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Arbel R, Hammerman A, Azuri J. Usefulness of Ezetimibe Versus Evolocumab as Add-On Therapy for Secondary Prevention of Cardiovascular Events in Patients With Type 2 Diabetes Mellitus. Am J Cardiol 2019; 123:1273-1276. [PMID: 30711247 DOI: 10.1016/j.amjcard.2019.01.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/07/2019] [Accepted: 01/11/2019] [Indexed: 01/31/2023]
Abstract
Evolocumab and ezetimibe, were both proven to significantly reduce the incidence of major adverse cardiovascular events (MACE), in type 2 diabetes patients with atherosclerotic cardiovascular disease and low-density lipoprotein (LDL) cholesterol >70 mg/dl despite statin therapy. Providing evolocumab for all such patients may be a significant burden on healthcare systems. Therefore, we analyzed the treatment cost of ezetimibe versus evolocumab to prevent 1 MACE. We extracted the number needed to treat (NNT) with evolocumab or with ezetimibe for avoiding MACE from the published FOURIER and IMPROVE-IT trials respectively. Drug costs were based on 2018 US prices. Sensitivity and scenario analyses were performed to overcome variances in terms of population risk, efficacy of therapies, and costs. In FOURIER, the 1-year NNT for avoiding MACE with evolocumab was 104 (95% confidence intervals [CI] 66 to 235). In IMPROVE-IT, the 1-year NNT with ezetimibe was 124 (95% CI 73 to 288). The annual cost of evolocumab and ezetimibe is $6,540 and $88, respectively. Therefore, the cost to prevent 1 MACE in the FOURIER and IMPROVE-IT trials would have been $678,981 (95% CI $429,810 to $1,537,910,149) and $10,870 (95% CI $6,384 to $25,322), respectively. Ezetimibe was consistently a cost-saving strategy compared with evolocumab, in all analyses performed, except for the case where evolocumab price is significantly reduced and the branded ezetimibe is used. In conclusion, treatment with ezetimibe seems to be a major cost-saving strategy for preventing MACE in this patient population.
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Bergethon KE, Wasfy JH. Increasing the Adoption and Diffusion of a Novel Pharmacological Therapy That Is Both Mortality Reducing and Cost-Effective. J Am Heart Assoc 2019; 8:e011783. [PMID: 30712487 PMCID: PMC6405583 DOI: 10.1161/jaha.118.011783] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
See Article by Luo et al
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Affiliation(s)
- Kristin E Bergethon
- 1 Department of Medicine Massachusetts General Hospital Harvard Medical School Boston MA
| | - Jason H Wasfy
- 2 Cardiology Division Department of Medicine Massachusetts General Hospital Harvard Medical School Boston MA
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