Defining the Role of PCSK9 Inhibitors in the Treatment of Hyperlipidemia

Cost-Effectiveness, Burden of Disease and Budget Impact of Inclisiran: Dynamic Cohort Modelling of a Real-World Population with Cardiovascular Disease

OBJECTIVE

We aimed to estimate the cost-effectiveness, burden of disease and budget impact of inclisiran added to standard-of-care lipid-lowering therapy in the real-world secondary cardiovascular prevention population in Switzerland.

METHODS

An open-cohort Markov model captured event risks by sex, age and low-density lipoprotein cholesterol based on epidemiological and real-world data. Low-density lipoprotein cholesterol reduction with add-on inclisiran was based on trial results and translated to meta-analysis-based relative risks of cardiovascular events. Unit costs for 2018 were based on publicly available sources, adopting a Swiss healthcare system perspective. Price assumptions of Swiss francs (CHF) 500 and CHF 3,000 per dose of inclisiran were evaluated, combined with uptake assumptions for burden of disease and budget impact. The assessment of cost-effectiveness used a discount rate of 3% per year. We performed deterministic and probabilistic sensitivity analyses, and extensive scenario analyses.

RESULTS

Patients treated with inclisiran gained a 0.291 qualityadjusted life-year at an incremental cost per QALY gained of CHF 21,107/228,040 (life-long time horizon, discount rate 3%) under the lower/higher price. Inclisiran prevented 1025 cardiovascular deaths, 3425 acute coronary syndrome episodes, and 1961 strokes in 48,823 patients ever treated during 10 years; the 5-year budget impact was CHF 49.3/573.4 million under the lower/higher price. Estimates were sensitive to calibration targets and treatment eligibility; burden of disease/budget impact results also to uptake. Limitations included uncertainties about model assumptions and the size and characteristics of the population modelled.

CONCLUSIONS

Inclisiran may be cost-effective at a willingness to pay of CHF 30,000 if priced at CHF 500; a threshold upwards of CHF 250,000 will be required if priced at CHF 3000. Inclisiran could enable important reductions in cardiovascular burden particularly under broader eligibility with a budget impact range from moderate to high depending on price.

Flaxseed and Its Components in Treatment of Hyperlipidemia and Cardiovascular Disease

This paper describes the effects of flaxseed and its components (flax oil, secoisolariciresinoldiglucoside[SDG], flax lignan complex [FLC], and flax fibers] on serum lipids (total cholesterol [TC], low-density lipoprotein-cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], and triglycerides [TG]) in animals and humans. Ordinary flaxseed reduces TG, TC, LDL-C, and TC/HDL-C levels in a dose-dependent manner in animals. In humans, it reduces serum lipids in hypercholesterolemicpatients but has no effects in normocholesterolemicpatients. Flax oil has variable effects on serum lipids in normo- and hypercholesterolemic animals. Flax oil treatment, with a dosage containing greater than 25 g/day of α-linolenic acid, reduces serum lipids in humans. Although FLC reduces serum lipids and raises serum HDL-C in animals, its effects on serum lipids in humans are small and variable. Flax fibers exert small effects on serum lipids in humans. Crop Development Centre (CDC)-flaxseed, which contains low concentrations of α-linolenic acid, has significant lipid lowering effects in animals. Pure SDG has potent hypolipidemic effects and raises HDL-C. In conclusion, flaxseed and pure SDG have significant lipid-lowering effects in animals and humans, while other components of flaxseed have small and variable effects.

Alirocumab Administration Experience to Achieve Low Density Lipoprotein Cholesterol Target Levels in Secondary Prevention of Cardiovascular Disease

Aim. To study the effects of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, alirocumab, on lipid levels in patients who receive secondary prevention of cardiovascular diseases (CVD) and require enhanced lipid-lowering therapy.

Material and methods. The study included 49 patients (aged of 61.53±1.14 years; 31 [63.3%] men) receiving alirocumab who did not reach the target low density lipoprotein cholesterol (LDL-C) concentrations despite the ongoing optimal lipid-lowering therapy. In all patients, the initial level of lipids was evaluated, as well as their parameters after subsequent alirocumab injections.

Results. LDL-C serum level significantly decreased after the first injection compared to the initial level from 2.92±0.22 to 1.65±0.19 mmol/L (p<0.001; Δ45.31±3.61%) and down to 1.74±0.17 mmol/L for the entire study period (p<0.001; Δ41.52±2.69%). The change in LDL-C level between injections did not show statistically significant differences (p=0.141). A direct strong statistically significant correlation between the LDL-C level after the first injection and its average values for the entire observation period was found (r=0.958, p<0.001).

Conclusion. The results of the study indicate that the PCSK9 inhibitor, alirocumab, in patients who need secondary prevention of CVD shows a significant additional decrease in the concentration of LDL-C after the first injection. At the same time, approximately half of the patients were able to achieve the recommended levels of LDL-C. The persistence of the achieved low LDL-C levels over time demonstrated that the average concentration of LDL-C during the observation corresponded to the values after the first injection. This finding shows that there is no need for constant monitoring of lipid metabolism parameters when prescribing such therapy.

Number of Patients Eligible for PCSK9 Inhibitors Based on Real-world Data From 2.5 Million Patients

INTRODUCTION AND OBJECTIVES

PCSK9 inhibitors (PCSK9i) are safe and effective lipid-lowering drugs. Their main limitation is their high cost. The aim of this study was to estimate the number of patients eligible for treatment with PCSK9i according to distinct published criteria.

METHODS

Data were obtained from the Information System for the Development of Research in Primary Care. Included patients were equal to or older than 18 years and had at least 1 low-density lipoprotein cholesterol measurement recorded between 2006 and 2014 (n = 2 500 907). An indication for treatment with PCSK9i was assigned according to the following guidelines: National Health System, Spanish Society of Arteriosclerosis, Spanish Society of Cardiology, National Institute for Health and Care Excellence, and the European Society of Cardiology/European Atherosclerosis Society Task Force. Lipid-lowering treatment was defined as optimized if it reduced low-density lipoprotein levels by ≥ 50% and adherence was > 80%.

RESULTS

Among the Spanish population aged 18 years or older, the number of possible candidates to receive PCSK9i in an optimal lipid-lowering treatment scenario ranged from 0.1% to 1.7%, depending on the guideline considered. The subgroup of patients with the highest proportion of potential candidates consisted of patients with familial hypercholesterolemia, and the subgroup with the highest absolute number consisted of patients in secondary cardiovascular prevention.

CONCLUSIONS

The number of candidates to receive PCSK9i in conditions of real-world clinical practice is high and varies widely depending on the recommendations of distinct scientific societies.

Prevention of Carotid Artery Atherosclerosis: What is the Evidence?

Carotid artery atherosclerosis (CAA) represents a significant form of atherosclerosis with stroke as a major consequence. Whether it is a unique form of atherosclerosis is not established. However, this is not of major clinical relevance as no specific preventive measures over and above the established ones for cardiovascular risk are well established. Major risk factors for CAA are elevated low-density lipoprotein cholesterol (LDL-C), diabetes mellitus, tobacco use, hypertension, and increased inflammation. Identification of CAA prior to a clinical event centers on imaging studies. Studies with magnetic resonance imaging result in the best definition of CAA plaque morphology. Medical measures that result in prevention are especially centered on statins (marked reduction of the LDL-C) and hypertension control. Nonprocedural therapeutic measures to avoid and delay complications involve antiplatelet medications. Benefits from other measures such as increasing high-density lipoprotein cholesterol and increased exercise appear desirable but require more clinical evidence. In conclusion, there are enough evidence-based medicine results to demand intensive medical preventive measures and not just relegate the patient with asymptomatic or symptomatic CAA to decision-making only involving the surgeon and interventionalist.

[Adaptive drug licensing: A chance for patients?]

In recent years, various options have been discussed to accelerate the approval of new drugs, especially for conditions with high unmet needs. There is a trade-off between the earlier availability of new treatment options and a potentially higher safety risk of drugs which have not been investigated in long-lasting clinical trials and a broader patient population. It must also be taken into account that clinical trial data and results must be sufficient to allow for the reimbursement of the new treatment option. The difficult process of weighting the benefits against the potential risks of an accelerated drug approval should be discussed between patients, regulatory authorities, HTA institutions and pharmaceutical companies. Patients might benefit from a fair, balanced accelerated approval.