Nonstatin Lipid-Lowering Therapy in Medicare Patients With Coronary Heart Disease
What are the time trends for use of statin and nonstatin lipid-lowering therapy (niacin, fibrates, bile acid sequestrants, and ezetimibe) among Medicare beneficiaries with coronary heart disease (CHD) in light of emerging clinical trial evidence?
A retrospective cohort study was conducted using the national 5% random sample of Medicare beneficiaries (n = 310,091). Twenty cohorts of individuals with CHD representing calendar quarters from 2007 through 2011 were utilized to assess trends in use of statins and nonstatin lipid-lowering medications.
Statin use increased from 53.1% to 58.8% between 2007 and 2011. Ezetimibe use peaked at 12.1% and declined to 4.6% by the end of 2011, declining among both patients on statins (18.4% to 6.2%) and not on statins (5.0% to 2.4%). Fibrate use increased from 4.2 to 5.0%, bile acid sequestrants did not change significantly, and niacin use increased from 1.5 to 2.4% and then declined in late 2011. Use of nonstatin lipid-lowering therapy was less common at older age, among African Americans, patients with heart failure, and patients with a higher Charlson co-morbidity score. Nonstatin lipid-lowering therapies were more common among men and patients with diabetes, those who had a cardiologist visit, and those taking statins.
The authors concluded that declining ezetimibe and niacin use but not fibrate therapy among Medicare beneficiaries with CHD coincides with negative clinical trial results for these agents.
It is a bit alarming that <60% of Medicare beneficiaries with CHD were taking statins, and not surprising that the nonstatin therapies were more commonly used when cardiologists were involved in care. Since the IMPROVE-IT trial demonstrated the benefit of ezetimibe, it still remains a tier 2 drug, and the costs have increased dramatically. With the approval of the novel PCSK9 antibody class, I expect many insurers will require the addition of ezetimibe prior to approval of the former at certain cutpoints of low-density lipoprotein cholesterol.
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