Cost-effectiveness of lipid lowering with statins and ezetimibe in chronic kidney disease

Abstract

Statin-based treatments reduce cardiovascular disease (CVD) risk in patients with non-dialysis chronic kidney disease (CKD), but it is unclear which regimen is the most cost-effective. We used the Study of Heart and Renal Protection (SHARP) CKD-CVD policy model to evaluate the effect of statins and ezetimibe on quality-adjusted life years (QALYs) and health care costs in the United States (US) and the United Kingdom (UK). Net costs below $100,000/QALY (US) or £20,000/QALY (UK) were considered cost-effective. We investigated statin regimens with or without ezetimibe 10 mg. Treatment effects on cardiovascular risk were estimated per 1-mmol/L reduction in low-density lipoprotein (LDL) cholesterol as reported in the Cholesterol Treatment Trialists' Collaboration meta-analysis, and reductions in LDL cholesterol were estimated for each statin/ezetimibe regimen. In the US, atorvastatin 40 mg ($0.103/day as of January 2019) increased life expectancy by 0.23 to 0.31 QALYs in non-dialysis patients with stages 3B to 5 CKD, at a net cost of $20,300 to $78,200/QALY. Adding ezetimibe 10 mg ($0.203/day) increased life expectancy by an additional 0.05 to 0.07 QALYs, at a net cost of $43,600 to $91,500/QALY. The cost-effectiveness findings and policy implications in the UK were similar. In summary, in patients with non-dialysis-dependent CKD, the evidence suggests that statin/ezetimibe combination therapy is a cost-effective treatment to reduce the risk of CVD.

Trial registration: ClinicalTrials.gov NCT00125593.

Keywords: chronic kidney disease; cost-effectiveness; ezetimibe; health care costs; quality-adjusted life years; statin.

Graphical abstract

Figure 1

Probability of a statin-based treatment to be cost-effective in moderate-to-advanced nondialysis chronic kidney disease (CKD) patients. Results shown for treatments on the cost-effectiveness frontier (i.e., the most cost-effective treatment for a given value of willingness to pay) within the range of willingness-to-pay values per quality-adjusted life-year (QALY). Typical cost-effectiveness thresholds are represented with dashed horizontal lines. Atorvastatin 20 mg daily was largely dominated by atorvastatin 40 mg daily and was omitted from the graph. LDL-C, low-density lipoprotein cholesterol; UK, United Kingdom; US, United States.

Figure 2

Cost-effectiveness of adding ezetimibe 10 mg to atorvastatin 40 mg daily for moderate-to-advanced nondialysis chronic kidney disease (CKD) patients, at different ezetimibe cost. The CKD and cardiovascular risk categories are derived directly from the 6235 moderate-to-advanced non–dialysis-dependent CKD patients in the Study of Heart and Renal Protection (SHARP). Typical cost-effectiveness thresholds are represented with dashed horizontal lines. *A total of 338 (17%) participants with CKD stage 3A (estimated glomerular filtration rate [eGFR] 60–45 ml/min per 1.73 m²). At the $100,000/quality-adjusted life-year [QALY] threshold in the United States (US) (a), ezetimibe 10 mg daily becomes cost-effective in all categories of patients when its price reaches $0.323/d. At the £20,000/QALY threshold in the United Kingdom (UK) (b), ezetimibe 10 mg daily becomes cost-effective in all categories of patients when its price reaches £0.019/d.