The Pharmaceutical Journal Vol 266 No 7148 p675-678
May 19, 2001

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The Journal

Real cost of LDL reduction

From Mr D. R. Petty, MRPharmS

The Journal reported recently on the Drug and Therapeutics Bulletin review, “Statin therapy — what now?” (PJ, March 24, p383). It seemed a strange choice of title for a review that offered no new insight into any future roles for statins. The DTB focused heavily on the wealth of evidence that already exists for the older statins in secondary prevention of coronary heart disease events. However, there is evidence that a reduction in serum cholesterol reduces coronary events and total mortality, regardless of the intervention used. In view of the evidence base, it would be unethical for any of the newer statins to be placed in large placebo controlled studies. Factors such as efficacy and cost efficacy are now the key questions in statin use.

As reported in your news item, the DTB recommends that simvastatin should be used as first-line therapy for preventing coronary heart disease. Those of us involved in managing drug budgets for primary care trusts will be justifiably concerned by this suggestion. Quite simply, to treat all patients with simvastatin to meet national cholesterol targets might prove too expensive.

If it is assumed that the lipid lowering benefits of statins are independent of the agent used, then cost becomes a primary concern. The DTB proposition for first-line drug choice is based not only on the evidence for CHD prevention, but also on a comparison of costs for monthly treatment with different statins. However, analysing cost effectiveness requires many factors to be considered, something that the DTB report fails to do. I have produced the following table, which your readers may find helpful, that shows better the real cost of low density lipoprotein cholesterol reduction using different statins.

References

1. Jones P, Kafonek S, Laurora I et al. Comparative dose efficacy study of atorvastatin versus simvastatin, pravastatin, lovastatin, and fluvastatin in patients with hypercholesterolemia (the Curves study). Am J Cardiol 1998;81:582-7).

2. Stein E. Cerivastatin in primary hyperlipidemia: A multicenter analysis of efficacy and safety. Am J Cardiol 1998;82:40J-46J

3. Ose L, Kastelein JP, Scott R et al. Efficacy of six-month safety of simvastain 80mg/day: Results from the worldwide simvastatin expanded dose program (WSEDP). Nutr Metab Cardiovasc Dis. 1998;8:135-43.

4. Ma P et al. Caveat: a randomised double blind parallel group evaluation of cerivastatin 0.4mg and 0.8mg compared to atorvastatin 10mg and 20mg once daily in patients with combined type (IIb) dyslipidaemia. Br J Cardiol 2000;7 (12):780-6

Duncan Petty
Division of Academic Pharmacy Practice, University of Leeds

Professor JOE COLLIER (editor, Drug and Therapeutics Bulletin) replies:

The letter criticises our selection of simvastatin as the statin of choice, arguing that there are equivalent drugs that should have been preferred. Simvastatin has advantages in that there are outcome data for it, its use is amenable to dose titration, it is licensed for secondary prevention and, even using the slightly quirky table, at high dosages, at least, it is comparatively cheap. Finally, there is a dividend from using older drugs for which there is greater experience and prescriber familiarity. Simvastatin is just such a drug.

Cost-effective statins

From Mr L. Furniss, MRPharmS

I was disappointed to read the comments about the Drug and Therapeutics Bulletin article on statins in a recent letter from a primary care pharmacist (PJ, May 5, p622). She appears to be taking a short-term approach to the development of a prescribing strategy for her primary care group.

In secondary prevention, simvastatin has been shown to reduce further cardiac events and mortality. Pravastatin is similar. Statins are known to have effects, other than lowering LDL-cholesterol, that may be important in preventing further events. Only studies that look at the clinical outcomes described above are able to take into account all of these factors. Unfortunately, this information is not available for all statins.

Furthermore, simvastatin is soon to become available as a generic medicine. Both patients and the National Health Service will then have the benefits of using a cost-effective statin. I wonder how the prescribing costs in the practice described in the letter will compare then? More importantly, a high quality, evidence-based treatment will have been provided for the patient. That is, of course, if “simvastatin XL” is not marketed!

Lee Furniss
London N16

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