High long-term persistence to evolocumab treatment regimens in European clinical practice: analysis of the HEYMANS registry

Background

Lipid-lowering treatments (LLTs) require both adherence and persistence to the treatment regimen long-term to maximise treatment benefits. Small molecules require self-medication daily but therapies such as evolocumab are labelled for self-medication every 2 weeks or monthly. Limited data exist concerning the long-term persistence to evolocumab in routine clinical practice.

Purpose

Using data from the HEYMANS registry, the objective of this analysis was to evaluate persistence and discontinuation of evolocumab in Europe.

Methods

HEYMANS was a prospective registry including adults initiating evolocumab treatment in routine clinical practice in 12 European countries between August 2015 and June 2020. Originally designed to have up to 12 months of follow-up, the protocol was amended (February 2018) to extend follow-up for up to 30 months. Patients yet to complete 12 months follow-up at this date, were followed up for up to 30 months. Therefore, we analysed evolocumab discontinuation separately for the two time periods: 0–12 months (all), 12–30 months (subset).

Results

Of the 1951 total patients, 30 patients discontinued participation in the study before 12 months (evolocumab use still ongoing at study discontinuation). Therefore, evolocumab use status was determined for 1921 patients at 12 months. Of these, 1781 (92.7%), remained on evolocumab at 12 months of follow-up (Figure). At 12 months, LDL-C levels were reduced from baseline by a median of 58% (Q1, Q3: 41%, 69%). In total, 1136 patients were eligible for extended follow up after protocol amendment. Of these, 137 patients discontinued study participation before 30 months of follow-up (with evolocumab ongoing). Therefore, evolocumab use status was determined in 999 patients, of whom, 92.2% (921) remained on evolocumab treatment at 30 months of follow-up (Figure). The reductions in LDL-C levels seen at 12 months were sustained throughout the study, with patients continuing to achieve median LDL-C reductions of 58% (Q1, Q3: 42%, 70%) from baseline at 30 months of follow-up.

Conclusions

In this real-world study, representative of European practice, of patients who entered the extension phase, the proportion of patients who remained on evolocumab up to 30 months exceeded 90%, and treatment was associated with sustained LDL-C reductions. These data suggest that the self-administration regimen of evolocumab is both feasible and acceptable in general populations, providing long-term sustained, reductions in LDL-C with likely associated health benefits.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen (Europe) GmbH

Evolocumab treatment is associated with early and sustained reductions in low-density cholesterol (LDL-C) over 30 months: final results from the pan-European observational HEYMANS registry

Background

Variability in LDL-C control at a population level associates with worse CV outcomes. This could in part be related to variations in patient adherence to self-administration regimens or variability in the response to a given therapy. Potent therapies such as PCSK9 inhibitors (PCSK9i) reduce cardiovascular events but some have questioned whether these therapies, which require dosing every 2 weeks, can offer sustained population level control of LDL-C.

Purpose

Using data from the HEYMANS registry, the objective of these analyses was to evaluate, at a population level, various metrics of variability in LDL-C reduction over time with evolocumab treatment.

Methods

HEYMANS was a prospective registry including adults initiating evolocumab treatment in clinical practice in 12 European countries between August 2015 to June 2020. Patient data were collected for ≤6 months before evolocumab initiation (baseline) and ≤30 months post initiation. LDL-C measurements were collected per clinical practice. At each 3-month time point in the study, we analysed median (and 95% CI) reductions in LDL-C, and the proportion of patients achieving ≥30% and ≥50% reductions in LDL-C from baseline.

Results

Data from 1951 patients were included in this final analysis (62% male, mean age 60 years, median baseline LDL-C 3.98 [Q1–Q3 3.17–5.07]) mmol/L). Most patients (85%) were receiving evolocumab for secondary prevention, with 40% not on oral LLT of whom the majority reported a history of statin intolerance. There was a median of 4 (Q1, Q3: 2, 6) LDL-C measurements per patient during follow-up. Within 3 months of initiating evolocumab treatment, LDL-C levels had reduced by a median of 58% and this reduction was maintained over 30 months (Figure 1). Among patients with an LDL-C value, ∼85% achieved a ≥30% reduction at each follow-up throughout the study, and ∼63% achieved a ≥50% reduction at each visit (Figure 2).

Conclusions

In European clinical practice, evolocumab treatment was associated with early and sustained reductions in LDL-C of over 30 months, with limited variability in LDL-C reductions at a population level. Within 3 months of treatment, evolocumab was associated with ∼58% reduction in LDL-C levels that was maintained throughout the study. These data should reassure the clinical community that meaningful, consistent additional reductions in LDL-C can be achieved with use of evolocumab. As greater use of combination therapies is required to achieve lower LDL-C goals, expanding the use of PCSK9i could provide improvements in population level control of LDL-C in European clinical practice.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen (Europe) GmbH

Potential cardiovascular risk reduction with evolocumab in the real world: a simulation in patients with a history of myocardial infarction from the HEYMANS register

Background/Introduction

FOURIER included 22,351 patients with a history of myocardial infarction (MI) and a median low-density lipoprotein cholesterol (LDL-C) of 2.4 mmol/L. Reducing LDL-C with evolocumab reduced the risk of major cardiovascular (CV) events by 1.3%, in absolute terms, over 2.2 years. Whether similar benefits might be observed in real-world evidence from evolocumab use is unknown.

Purpose

Simulate CV risk and assess the potential CV risk reduction among a large European cohort of evolocumab users with a history of MI.

Methods

We used interim data from HEYMANS, a register of patients initiating evolocumab in routine clinical practice across 12 European countries, from August 2015 with follow-up through July 2020. Demographic and clinical characteristics, lipid-lowering therapy (LLT), and lipid values were collected from routine medical records (6 months prior to evolocumab initiation through 30 months post initiation). Patients with a history of MI were considered and two sub-cohorts were created: recent MI (MI ≤1 year before evolocumab initiation) and remote MI (MI >1 year before evolocumab initiation). For each patient, we 1) simulated their CV risk using three different sources, correcting for age and LDL-C: i) the REACH equation, ii) FOURIER, iii) an observational study including FOURIER-like patients; 2) calculated their absolute LDL-C reduction on evolocumab; 3) simulated their relative risk reduction (RRR) by randomly sampling from the inverse probability distribution of the rate ratio per 1 mmol/L from the key secondary endpoint in the FOURIER landmark analysis; 4) calculated their absolute risk reduction (ARR) and number needed to treat (NNT) over 2 years (recent MI) or 10 years (remote MI).

Results

Our analysis included 90 recent MI and 489 remote MI patients initiating evolocumab in clinical practice per local reimbursement criteria, with up to 24 months follow-up. Median (inter-quartile range) age was 59 (53–67) and 61 (53–68) years in recent MI and remote MI patients, respectively. LDL-C before evolocumab was 3.8 (3.2–4.6) and 3.6 (3.0–4.5) mmol/L. Absolute LDL-C reduction on evolocumab was 2.2 (1.4–2.8) and 2.2 (1.6–2.8) mmol/L, meaning relative LDL-C reduction of 60% (44%-73%) and 62% (47%-72%), respectively. Predicted ARR with evolocumab was substantial, whether over 2 years (recent MI) or over 10 years (remote MI). See Table 1.

Conclusions

This cohort of evolocumab users in clinical practice had a higher baseline LDL-C and CV risk than patients enrolled in FOURIER. LDL-C reduction and RRR were very similar in recent MI and remote MI patients. However, patients with a recent MI had a higher short-term CV risk and therefore showed a larger ARR on evolocumab.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen

Evolocumab use in Europe: clinical guidelines vs. reimbursement thresholds – results from the HEYMANS study

Background

2019 ESC/EAS guidelines recommend a 50% lowering in untreated LDL-C and use of PCSK9 inhibitors (PCSK9i) for patients (pts) at very high cardiovascular (CV) risk when LDL-C goals of <1.4mmol/L are not met despite maximally tolerated statins and ezetimibe. However, the LDL-C threshold at which PCSK9i are reimbursed are higher than the goals recommended in clinical guidelines.

Purpose

This prospective observational cohort study describes clinical characteristics and LDL-C control among pts initiating evolocumab across 12 EU countries.

Methods

Pts are followed from evolocumab initiation (baseline). Demographic/clinical characteristics, lipid lowering therapy (LLT) and lipid values are being collected from medical records (6 months before evolocumab up to 30 months post initiation). We report interim data from pts initiating evolocumab from August 2015 followed-up until July 2020.

Results

Of the 1,952 pts in whom evolocumab was initiated as per local reimbursement criteria, most (1844 [94%]) had 12 months follow-up, 785 (40%) had 24 months follow-up; mean follow-up: 20 months. Mean (SD) age was 60 (10.8) years; 85% of pts had a history of CV disease, 45% had familial hypercholesterolemia, 19% had type 2 diabetes, 65% were hypertensive, 7% had chronic kidney disease and 51% were prior/current smokers. At evolocumab initiation, 60% reported statin intolerance and 41% were on no background LLT. Fewer than half (846 [43%]) were receiving a statin (± ezetimibe); of these, most received a high/moderate intensity (68%/22%), with 13% receiving statin monotherapy. Median (Q1, Q3) baseline LDL-C was 3.98 (3.17, 5.07) mmol/L. Within 3 months of initiation median LDL-C fell by 58% to 1.63mmol/L. This reduction was maintained over time (Figure 1). Overall, 58% of pts achieved at least one LDL-C <1.4mmol/L during follow-up. Among pts receiving background statins ± ezetimibe at evolocumab initiation, 67% (710/1053) achieved at least one LDL-C <1.4mmol/L, versus 44% (317/714) of pts not receiving background statins/ezetimibe. During follow-up background oral LLT did not materially change; 40–45% pts received no LLT, 41–44% received statin ± ezetimibe, 12–14% received statin monotherapy.

Conclusion

In Europe, pts initiated on evolocumab had baseline LDL-C levels almost 3x higher than the present threshold for PCSK9i use recommended in guidelines reflecting disparities between local reimbursement criteria and guidelines. Although evolocumab led to a >50% reduction in LDL-C, only ∼50% pts achieved an LDL-C <1.4mmol/L, as approximately 41% received only evolocumab as monotherapy. LDL-C goal attainment was however higher among pts receiving evolocumab with background LLT. Therefore, lowering the LDL-C threshold for PCSK9i reimbursement, would result in more patients receiving combination therapy with oral LLT plus PCSK9i, thus increasing the likelihood of more pts achieving very-high risk LDL-C goals.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen Europe GmbH

Does Evolocumab use in Europe match 2019 ESC/EAS lipid guidelines? Results from the HEYMANS study

Background

2019 ESC/EAS dyslipidaemia guidelines recommend a 50% lowering in untreated LDL-C and use of PCSK9 inhibitors (PCSK9i) for patients at very-high cardiovascular (CV) risk when LDL-C target goals of <1.4 mmol/L or <1.0 mmol/L (for those with 2 CV events within two-years) are not met despite maximally tolerated statins and ezetimibe.

Purpose

This observational study describes a cohort of patients initiating evolocumab across 10 EU countries.

Methods

Patients are followed from evolocumab initiation (baseline). Demographic/clinical characteristics, lipid modifying therapy (LLT) and lipid values were collected from medical records (6 months prior to evolocumab initiation through 30 months post initiation). We report interim data from patients initiating evolocumab from August 2015 with follow-up through October 2019.

Results

1896 patients initiated on evolocumab as per local reimbursement criteria were included in this interim analysis (planned sample size: N=2,000). Most (1663 [88%]) had 12 months follow-up, 665 (35%) had 18 months follow-up; mean follow-up, 16.3 months. Mean (SD) age was 60.0 (10.8) years; 85% of patients had a history of CV disease (CVD), 44% had a diagnosis of familial hypercholesterolemia (FH), 19% had type 2 diabetes, 66% were hypertensive, 7% had renal impairment and half (51%) were prior or current smokers. The majority (60%) reported statin intolerance and 42% were not receiving any LLT at evolocumab initiation. Fewer than half (805 [43%]) were receiving a statin (±ezetimibe) at evolocumab initiation; of these, most were on a high/moderate intensity (68%/22%). 12% of patients were receiving statin monotherapy. Median (Q1, Q3) baseline LDL-C was 3.98 (3.16, 5.06) mmol/L. Within 3 months of evolocumab initiation median LDL-C fell by 58% to 1.62 mmol/L. This reduction was maintained over time (Figure). Overall, 58% of patients achieved at least one LDL-C <1.4 mmol/L during follow-up. Among patients receiving background statins and/or ezetimibe at evolocumab initiation, 67% (667/990) achieved at least one LDL-C <1.4 mmol/L, compared with 43% (295/679) of patients not receiving background statins/ezetimibe. During follow-up, 39–46% patients received no background LLT, 40–44% received statin ±ezetimibe, 11–14% received statin monotherapy.

Conclusion

In Europe, patients initiated on evolocumab had baseline LDL-C levels almost 3 times higher than the present threshold for PCSK9i use, reflecting local reimbursement criteria. Evolocumab resulted in a more than 50% reduction in LDL-C; however, only approximately half of all patients achieved an LDL-C <1.4 mmol/L. LDL-C goal attainment was higher among patients receiving evolocumab with background LLT, suggesting that achievement of EAS/ESC LDL-C goals requires multiple LLTs and a lower threshold for PCSK9i initiation.

LDL-C levels after evolocumab initiation

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Amgen

What potential risk reduction could be achieved with evolocumab treatment? A simulation based on observational data from a cohort of users in 10 European countries

Background/Introduction

The FOURIER trial enrolled very high-risk patients with a mean LDL-C of 2.5 mmol/L, and demonstrated that evolocumab reduced major cardiovascular events by 1.5% in absolute terms over 2.2 years. Further research may be conducted to understand the potential benefits of evolocumab in the real world.

Purpose

Predict/simulate baseline CV risk and assess potential risk reduction among a large European cohort of evolocumab users.

Methods

We used interim data from an observational study of patients initiating evolocumab across 10 European countries from August 2015 with follow-up through October 2019. Demographic and clinical characteristics, lipid-lowering therapy (LLT) and lipid values were collected from routine medical records (6 months prior to evolocumab initiation through 30 months post initiation). For each patient, we 1) predicted/simulated their 10-year CV risk using three different approaches: i) a prediction using REACH score, ii) a simulation based on FOURIER trial patients, iii) a simulation based on real-world FOURIER-like patients from a published obervational study; 2) calculated their absolute LDL-C reduction on evolocumab treatment; 3) simulated their relative risk reduction (RRR) by randomly sampling from the probability distribution of the rate ratio per 1 mmol/L from the key secondary endpoint in the FOURIER trial landmark analysis; 4) calculated their absolute risk reduction (ARR).

Results

Our analysis included 779 patients initiating evolocumab in clinical practice per local reimbursement criteria, with up to 18 months follow-up. Mean (SD) age was 62.7 (9.6) years and mean (SD) baseline LDL-C was 3.85 (1.39) mmol/L. Mean (SD) absolute LDL-C reduction on evolocumab was 2.1 (1.2) mmol/L. Predicted/simulated 10-year CV risk, RRR and ARR are presented in Table 1. Simulated probability distributions (based on FOURIER) for 10-year CV risk before and after evolocumab treatment are shown in Figure 1.

Conclusion(s)

This cohort of evolocumab users in clinical practice had an almost 2-fold higher baseline LDL-C than patients enrolled in FOURIER trial, which translated to higher baseline CV risk. For that reason, the estimated 10-year absolute benefit in this cohort was larger than expected based on FOURIER trial results.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Amgen

P654Effectiveness of evolocumab for patients with familial hypercholesteraemia (FH) in European clinical practice

Background

FH is a genetic disorder which causes lifelong elevations in LDL-C from birth, resulting in a significantly increased risk of premature atherosclerotic cardiovascular disease (ASCVD). In clinical trials among patients with heterozygous FH (HeFH) and homozygous FH (HoFH), evolocumab significantly reduced LDL-C by approximately 40–60% from baseline. Few data are available on evolocumab use among FH patients treated in a real-world setting.

Purpose

Describe the characteristics of FH patients receiving evolocumab in routine clinical practice and their response to therapy.

Methods

This observational study across 10 European countries follows subjects from the date of evolocumab initiation (baseline) for up to 2.5 years, with relevant clinical data abstracted from medical charts (for subjects on apheresis, LDL-C measures included those obtained directly following apheresis). We analysed a cohort of FH subjects from an interim analysis which included subjects initiating evolocumab from Aug 2015 through Jun 2018. FH was diagnosed by the treating physician using standard criteria.

Results

A total of 502 FH subjects were included, 477 had HeFH (95%) and 25 HoFH (5%). The main diagnostic methods used included: the Dutch Lipid Clinic Network criteria (39% of HeFH, 28% of HoFH), genetic testing (27% of HeFH, 36% of HoFH), LDL-C values alone (23% HeFH, 16% HoFH). Mean (95% Confidence Interval [CI]) age was 58 (57–59) years for HeFH and 56 (50–61) for HoFH; 71% and 84% <65 years, respectively. 60% of HeFH subjects were male (HoFH: 40% male). In the overall FH cohort, additional CV risk factors were common (59% hypertension, 15% diabetes, 6% chronic kidney disease ≥ stage 2, 17% current smoker, 22% BMI≥30), with the majority having experienced a prior CV event (77% of HeFH, 80% of HoFH). Among HeFH subjects, 40% were receiving a high intensity statin at baseline, 11% medium intensity, 2% low intensity and 47% no statins. For HoFH, the corresponding values were 36%, 16%, 0 and 40%, respectively. Baseline ezetimibe use was 53% in HeFH and 48% in HoFH. Among HeFH patients, median (IQR) baseline LDL-C was 4.30 (3.41, 5.50) mmol/L; this dropped to 1.73 (1.03, 2.97) mmol/L within 3 months of evolocumab initiation, median LDL-C reduction 56% (Figure 1). Only 20 HoFH patients had a baseline LDL-C value; median (IQR), 4.07 (2.68, 6.17) mmol/L which dropped to 2.59 (1.63, 3.40) by month 3 [n=16]. No serious and no fatal adverse reactions were observed.

Figure 1

Conclusions

In this real-world study of evolocumab use in clinical practice, a large proportion of FH patients were not on statins and had LDL-C levels >4 mmol/L. After initiation of evolocumab median LDL-C fell by about one half in HeFH and by about one third in HoFH. Evolocumab was well-tolerated.

Acknowledgement/Funding

This study was fully funded by Amgen Inc