Cost-Effectiveness Analysis of Combination Statin/Ezetimibe Therapy for the Treatment of Elevated Low-Density Lipoprotein Cholesterol

Abstract

Purpose

Although statins have been shown to reduce LDL-C and coronary heart disease risk, it is not uncommon for patients to fail to reach NCEP ATP III goals. Some statins cannot lower LDL-C sufficiently; others cannot be titrated optimally due to drug interactions and adverse effects. Concomitant ezetimibe administration can augment LDL-C reduction over statin monotherapy; however, multidrug therapy may result in additional expense.

Methods

We conducted a cost-effectiveness analysis (CEA) from the hospital perspective including all FDA approved statins alone (fluvastatin, lovastatin, pravastatin, simvastatin, rosuvastatin, or atorvastatin) or the following statins plus ezetimibe: lovastatin, pravastatin, simvastatin, or atorvastatin. LDL-C lowering efficacy was determined from clinical trials. Our institution's actual acquisition cost was used to approximate drug cost (US $2,004) for each statin dose alone and with ezetimibe. To test the robustness of our results a Monte Carlo simulation was conducted varying both the cost of drug and percent LDL-C reduction efficacy.

Results

For patients requiring less than or equal to 40% reduction from baseline in LDL-C, lovastatin 10, 20, or 40 mg, or fluvastatin 80 mg would appear to be reasonable choices based upon both efficacy and cost data. For reductions in LDL-C in the range of greater than 40%; simvastatin 40 mg plus ezetimibe 10 mg was found to be most cost effective; although, simvastatin 80 mg, rosuvastatin 20 or 40 mg, or simvastatin 80 mg plus ezetimibe 10 mg appear to be reasonably cost-effective as well. These results were not found to be robust to variations in drug cost and LDL-C reduction.

Conclusion

When smaller reductions in LDL-C are required (less than 40%), drug cost is the variable that most significantly drives cost effectiveness; however, when larger LDL-C reductions are required, LDL-C lowering capacity is the single most important factor in determining cost-effectiveness of the lipid-lowering therapies. The addition of ezetimibe becomes most cost-effective when larger reductions are required.