Are Intensive Lipid-lowering Regimens an Optimal Economic Strategy in Patients with ACS? An Acute and Chronic Perspective

Roberta Ara; Rachid Rafia; Sue E Ward; Anthony S Wierzbicki; Tim M Reynolds; Angie Rees; Abdullah Pandor


Expert Rev Pharmacoeconomics Outcomes Res. 2009;9(5):423-433. 

In This Article

Abstract and Introduction


A literature review was conducted to identify studies exploring the cost–effectiveness of intensive lipid-lowering regimens compared with a generic low-dose statin for individuals with acute coronary syndrome. Three papers matched the inclusion criteria. All used a Markov model to represent the long-term clinical pathway; two were set in the UK and one was in the USA. While there were substantial differences in the effectiveness data, the definitions of the health states and the numbers of events predicted, all authors found that the intensive regimen was a cost-effective alternative compared with a generic lower dose statin. If the cost of atorvastatin reduces from GBP£ 368 to £90 per annum when the patent expires in 2011, atorvastatin 80 mg/day would be the most optimal treatment for this patient group. Simvastatin 80 mg/day should not be considered an alternative owing to an adverse safety profile and limited additional benefits.


Although there has been a decrease in coronary heart disease (CHD) mortality rates over the last two decades, in 2005, 30% of all global deaths (an estimated 17.5 million) were attributed to cardiovascular disease (CVD).[1] In the UK, CVD is still the most common cause of death, accounting for almost 198,000 deaths per annum.[101] While mortality rates are on the decline, CVD morbidity appears to be rising. Data from the Health Surveys for England suggest that prevalence rates for CHD and stroke have increased from 7.1 to 8.1% and 5.2 to 5.6% for males and females, respectively, over the period 1998–2006.[102] Conservative estimates suggest there are approximately 113,000 myocardial infarctions, 96,000 new cases of angina and 68,000 new cases of heart failure per year in the UK.[101]

The overall annual economic cost associated with CVD in the UK has been estimated to be £30.7 billion a year, and the £14.4 billion (47%) attributable to direct healthcare costs constitute approximately 12% of all healthcare costs for the National Health Service (NHS).[101] With lipid-lowering treatments contributing to a large proportion of the £2.9 billion attributed to drug costs,[101] there has been a shift in policy with recommendations to prescribe generic simvastatin, irrespective of the underlying risk of the patient. However, these recommendations are formed on the basis of drug acquisition costs only and do not take into account the potential costs associated with subsequent cardiovascular events in individuals who may benefit from a more intensive preventative strategy.

The most frequently prescribed statins in the UK are pravastatin, simvastatin, atorvastatin and rosuvastatin.[103] As pravastatin and simvastatin are available as generic treatments, their costs are tenfold lower than those of the latter two. However, dose for dose the generic statins are less potent than the newer branded statins. In terms of reductions in low-density lipoprotein cholesterol levels (LDL-C), simvastatin 20(40) mg/day, atorvastatin 10(20) mg/day and rosuvastatin 5(10) mg/day are considered to be approximately equivalent, while pravastatin 40 mg/day (the maximum licensed dose in the UK) is approximately equal to simvastatin 20 mg/day. Simvastatin 20 or 40 mg/day are generally regarded as standard treatment for primary and secondary prevention, respectively.

While the cost–effectiveness of statins compared with no treatment are well established, studies exploring the comparative cost–effectiveness of individual statins (either as monotherapy or combined with ezetimibe) are generally limited to lower dose regimens. We conducted a systematic literature search to identify economic evaluations comparing a more intensive lipid-lowering regimen to a standard-dose generic statin (or the equivalent potency of a branded statin) in individuals with acute coronary syndrome (ACS).

For the purpose of this review, an intensive lipid-lowering strategy was defined as either atorvastatin 80 mg/day, rosuvastatin 40 mg/day or simvastatin 80 mg/day monotherapy; or ezetimibe 10 mg/day combined with either simvastatin 40 mg/day, atorvastatin 40 mg/day or rosuvastatin 20 mg/day. Standard dose was defined as generic simvastatin 20 mg/day, simvastatin 40 mg/day, atorvastatin 10 mg/day or pravastatin 40 mg/day. It should be noted that we have concerns with regard to the safety and tolerance rates for simvastatin 80 mg/day and do not consider this to be an option for intensive lipid-lowering.[2,104] Studies exploring the cost–effectiveness of simvastatin 80 mg/day were included for completion as the safety profile for the higher dose has only recently emerged.


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