Eligibility for alirocumab or evolocumab treatment in 1090 hypercholesterolemic patients referred to a regional cholesterol treatment center with LDL cholesterol ≥70 mg/dL despite maximal-tolerated LDL-cholesterol-lowering therapy

Abstract

Background: Proprotein convertase subtilisin/kexin type 9 inhibitors, Praluent (alirocumab [ALI]) and Repatha (evolocumab [EVO]) have been approved as adjuncts to the standard-of-care maximal-tolerated dose (MTD) of low-density lipoprotein cholesterol (LDLC)-lowering therapy (LLT), statin therapy, in heterozygous (HeFH) (ALI or EVO) or homozygous (EVO) familial hypercholesterolemia, or clinical atherosclerotic cardiovascular disease (CVD) where LDLC lowering is insufficient (both). Since LDLC lowering has been revolutionized by ALI and EVO, specialty pharmaceutical pricing models will be applied to a mass market.

Methods: We applied US Food and Drug Administration (FDA) and insurance eligibility criteria for ALI and EVO to 1090 hypercholesterolemic patients serially referred over 3 years who then received ≥2 months maximal-tolerated dose of standard-of-care LDL cholesterol-lowering therapy (MTDLLT) with follow-up LDLC ≥70 mg/dL. MTDLLT did not include ALI or EVO, which had not been commercially approved before completion of this study.

Results: Of the 1090 patients, 140 (13%) had HeFH by clinical diagnostic criteria and/or CVD with LDLC >100 mg/dL despite ≥2 months on MTDLLT, meeting FDA insurance criteria for ALI or EVO therapy. Another 51 (5%) patients were statin intolerant, without HeFH or CVD.

Conclusion: If 13% of patients with HeFH-CVD and LDLC >100 mg/dL despite MTDLLT are eligible for ALI or EVO, then specialty pharmaceutical pricing models (~$14,300/year) might be used in an estimated 10 million HeFH-CVD patients. Whether the health care savings arising from the anticipated reduction of CVD events by ALI or EVO justify their costs in populations with HeFH-CVD and LDLC >100 mg/dL despite MTDLLT remains to be determined.

Keywords: PCSK9; Praluent (alirocumab); Repatha (evolocumab); atherosclerotic cardiovascular disease; cholesterol; heterozygous familial hypercholesterolemia; hyperlipidemia; proprotein convertase subtilisin/kexin type 9 inhibitors; statin.

Figure 1

HeFH and atherosclerotic CVD in 1090 patients with LDLC ≥70 mg/dL after ≥2 months maximal-tolerated cholesterol-lowering therapy. Notes: One hundred forty patients with HeFH and/or CVD (13% of the referred cohort) eligible for PCSK9 inhibitor therapy by US Food and Drug Administration and commercial insurance guidelines by virtue of LDLC on maximal-tolerated therapy >100 (dosage was MTDLLT, which included zero dose statin for those with statin intolerance). Abbreviations: CVD, cardiovascular disease; HeFH, heterozygous familial hypercholesterolemia; LDLC, low-density lipoprotein cholesterol; MTDLLT, maximal-tolerated dose of standard-of-care LDL cholesterol-lowering therapy; PCSK9, proprotein convertase subtilisin/kexin type 9.