The statin wars

Statin-associated muscular and renal adverse events: data mining of the public version of the FDA adverse event reporting system

Objective

Adverse event reports (AERs) submitted to the US Food and Drug Administration (FDA) were reviewed to assess the muscular and renal adverse events induced by the administration of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) and to attempt to determine the rank-order of the association.

Methods

After a revision of arbitrary drug names and the deletion of duplicated submissions, AERs involving pravastatin, simvastatin, atorvastatin, or rosuvastatin were analyzed. Authorized pharmacovigilance tools were used for quantitative detection of signals, i.e., drug-associated adverse events, including the proportional reporting ratio, the reporting odds ratio, the information component given by a Bayesian confidence propagation neural network, and the empirical Bayes geometric mean. Myalgia, rhabdomyolysis and an increase in creatine phosphokinase level were focused on as the muscular adverse events, and acute renal failure, non-acute renal failure, and an increase in blood creatinine level as the renal adverse events.

Results

Based on 1,644,220 AERs from 2004 to 2009, signals were detected for 4 statins with respect to myalgia, rhabdomyolysis, and an increase in creatine phosphokinase level, but these signals were stronger for rosuvastatin than pravastatin and atorvastatin. Signals were also detected for acute renal failure, though in the case of atorvastatin, the association was marginal, and furthermore, a signal was not detected for non-acute renal failure or for an increase in blood creatinine level.

Conclusions

Data mining of the FDA's adverse event reporting system, AERS, is useful for examining statin-associated muscular and renal adverse events. The data strongly suggest the necessity of well-organized clinical studies with respect to statin-associated adverse events.

The break-even point: when medical advances are less important than improving the fidelity with which they are delivered

Society invests billions of dollars in the development of new drugs and technologies but comparatively little in the fidelity of health care, that is, improving systems to ensure the delivery of care to all patients in need. Using mathematical arguments and a nomogram, we demonstrate that technological advances must yield dramatic, often unrealistic increases in efficacy to do more good than could be accomplished by improving fidelity. In 2 examples (the development of anti-platelet agents and statins), we show that enhanced efficacy failed to achieve the health gains that would have occurred by delivering older agents to all eligible patients. Society's huge investment in technological innovations that only modestly improve efficacy, by consuming resources needed for improved delivery of care, may cost more lives than it saves. The misalignment of priorities is driven partly by the commercial interests of industry and by the public's appetite for technological breakthroughs, but health outcomes ultimately suffer. Health, economic, and moral arguments make the case for spending less on technological advances and more on improving systems for delivering care.

Cost-efficacy analysis of 3-hydroxy-3-methylglutaryl coenzyme a reductase inhibitors based on results of the STELLAR trial: clinical implications for therapeutic selection

STUDY OBJECTIVE

To compare the cost/1% reduction in low-density lipoprotein cholesterol (LDL) and the cost/patient achieving the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) LDL goal based on the results of the Statin Therapies for Elevated Lipid Levels Compared Across Doses to Rosuvastatin (STELLAR) trial.

DESIGN

Cost-efficacy analysis.

INTERVENTION

Investigators in the STELLAR trial evaluated percentage reductions in LDL and achievement of the ATP III LDL goal for various doses of atorvastatin, pravastatin, rosuvastatin, and simvastatin. We derived efficacy estimates for these four statins from the results of this trial. We also derived drug acquisition costs from the average wholesale prices to estimate the cost/1% reduction in LDL levels and the cost/patient achieving the ATP III LDL goal.

MEASUREMENTS AND MAIN RESULTS

In the STELLAR trial, doses of rosuvastatin produced reductions in LDL significantly greater than those of equivalent milligram/milligram doses of atorvastatin, simvastatin, or pravastatin. The annual acquisition cost/percentage LDL reduction was lower with rosuvastatin at doses of 10 mg (20.92 dollars), 20 mg (18.28 dollars), and 40 mg (17.42 dollars) than with the other statins analyzed. Rosuvastatin also had a lower average cost/patient achieving the ATP III LDL goal over 6 weeks than that of the other statins.

CONCLUSION

Although the long-term clinical benefits and safety data from the increased LDL reduction achieved with rosuvastatin remain uncertain, rosuvastatin may be the most cost-effective statin among those analyzed in terms of acquisition cost/1% reduction in LDL levels and in terms of patients achieving ATP III LDL goals. On the basis of the efficacy estimates from the STELLAR trial in conjunction with acquisition cost, a potential cost savings could be realized from the use of rosuvastatin.