Should Cost of Therapy Be Considered in Cardiovascular Guidelines?

Michelle L. O'Donoghue, MD, MPH


March 06, 2017

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Hi. This is Dr Michelle O'Donoghue, reporting for Medscape.

The American College of Cardiology's Scientific Session in Washington, DC, is fast approaching. Along with that, one of the hot topics that I'm interested in seeing the results of is FOURIER. This is going to be the first phase 3 trial result of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor.

Certainly, there is a lot of enthusiasm about this class of therapies. They have been demonstrated to reduce low-density lipoprotein (LDL) cholesterol by about 60%,[1,2,3] but along with that, there has also been a lot of discussion about the associated cost.[4] Certainly, this is not the first novel medication to come with a high price tag, but I think it has been getting a lot of attention, and for that reason I wanted to bring this topic up for consideration.

I was thinking about it this morning: When physicians are drafting guidelines, should they be factoring cost into part of that assessment? One could make an argument that physicians are not really in the best position to be making assessments about cost benefit. Given the types of cost-effectiveness analyses that are typically conducted, I have to admit that most physicians are probably not experts in that particular area. Physicians are in a better position to weigh the relative efficacy and safety of a therapy.

But I was curious to get people's opinions about whether or not cost is something that should be factored in a guideline recommendation. Should guidelines be based purely on the weight of the clinical trial data, or should the physicians also be taking a step back and considering as well what the cost to payers will be?

It is challenging, because we have these emerging therapies-not just PCSK9 inhibitors but also other novel therapies that have demonstrated benefit, such as Entresto (sacubitril/valsartan) or some of the newer diabetes medications. These are more expensive than the older generic therapies, but they have also demonstrated clear benefit.

Where should that factor in? I am interested to get your thoughts on this. I have to say that my own personal feeling is that cost should probably not be factored in-that we should be leaving that to the payers to decide, and the guidelines should really just be putting forth the efficacy and safety of the compounds and offering recommendations on that basis.

I am sure there are some differing opinions out there, so I am looking forward to hearing them.

Signing off for Medscape, this is Dr Michelle O'Donoghue.


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