Management of Hypercholesterolemia - Episode 4

Future Outlook: Treating With PCSK9 Inhibitors

August 15, 2019

Deepak L. Bhatt, MD, MPH: The use of PCSK9 inhibitors is likely to grow in coming years as physicians’ familiarity and comfort levels increase. The data from both FOURIER and ODYSSEY are quite strong in terms of reductions in important ischemic events, and with really great safety profiles. For patients who, for example, are intolerant to statins, it is important to send them to a specialized lipid clinic. But patients who are tolerant to statins, on whatever dose they’re able to tolerate, get insufficient LDL [low-density lipoprotein] cholesterol reduction, the addition of a PCSK9 inhibitor can be very useful. That could apply to a rather large number of patients.

There have been concerns about the costs associated with these agents. Both agents that are FDA approved, evolocumab and alirocumab, when they came out, the prices were much higher than they are now. At their initial pricing, it really was a challenge getting patients to take them because coverage of these drugs wasn’t so great. Unfortunately, I think that left a bad taste in many physicians’ mouths. But things have changed since that time, in terms of the price of each of those agents coming down quite a bit.

And now in appropriately selected patients, studies have shown that they actually are cost-effective. That’s not to say that they’re inexpensive, but just like many of the other advances in medicine, or in cardiovascular medicine, with things like SGLT2 inhibitors and GLP1 agonists, for example, in diabetes, we’ve got great data. And cost-effectiveness in the right patient is really quite reasonable. In the case of PCSK9 inhibitors—particularly when the LDL cholesterol remains above 100 [mg/dL] despite the physician’s best attempt to max out the statin dose—to add on ezetimibe, of course to push weight loss and a plant-based diet…When all that hasn’t done the trick, when the LDL is still above 100 [mg/dL], the drugs really do seem to be quite cost-effective.

Transcript edited for clarity.