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Nonstatin Lipid-Lowering Therapy in Medicare Patients With Coronary Heart Disease
Study Questions:
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?
Methods:
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.
Results:
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.
Conclusions:
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.
Perspective:
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.
Keywords: Bile Acids and Salts, Cholesterol, LDL, Cholesterol, Coronary Disease, Diabetes Mellitus, Dyslipidemias, Fibric Acids, Geriatrics, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypolipidemic Agents, Lipoproteins, LDL, Medicare, Niacin, Primary Prevention
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