Trends in Lipid-Lowering Prescriptions: Increasing Use of Guideline-Concordant Pharmacotherapies, U.S., 2017‒2022

Abstract

Introduction: Almost one third of U.S. adults have elevated low-density lipoprotein cholesterol, increasing their risk of atherosclerotic cardiovascular disease. The 2018 American College of Cardiology/American Heart Association Multisociety Cholesterol Management Guideline recommends maximally tolerated statin for those at increased atherosclerotic cardiovascular disease risk and add-on therapies (ezetimibe and PCSK9 inhibitors) in those at very high risk and low-density lipoprotein cholesterol ≥70 mg/dL. Prescription fill trends are unknown.

Methods: Using national outpatient retail prescription data from the first quarter of 2017 to the first quarter of 2022, authors determined counts of patients who filled low-, moderate-, or high-intensity statins alone and with add-on therapies. The overall percentage change and joinpoint regression were used to assess trends. Analyses were conducted in March 2022-May 2022.

Results: During the first quarter of 2017 to the first quarter of 2022, patients filling a statin increased by 25.0%, with the greatest increase in high-intensity statins (64.1%, range=6.6-10.9 million). Low-intensity statins decreased by 29.2% (range=3.3-2.4 million). Concurrent fills of high-intensity statin and ezetimibe rose by 210% to 579,012 patients by the first quarter of 2022, with an increase in slope by the first quarter of 2019 for all statin intensities (p<0.01). Concurrent fills of a statin and PCSK9 inhibitor increased to 2,629, 16,169, and 28,651 by the first quarter of 2022 for low-, moderate-, and high-intensity statins, respectively. For patients on all statin intensities and PCSK9 inhibitor, there were statistically significant increases in slope in the second quarter of 2019 and decreases in the first quarter of 2020.

Conclusions: Patients filling moderate- and high-intensity statins and add-on ezetimibe and PCSK9 inhibitors have increased, indicating uptake of guideline-concordant lipid-lowering therapies. Improvements in the initiation and continuity of these therapies are important for atherosclerotic cardiovascular disease prevention.

Appendix Figure 1.

Projected number of patients filling concurrent statin and PCSK9 inhibitor from outpatient retail pharmacies, stratified by statin intensity, Q1 2017‒Q1 2022. IQVIA Total Patient Tracker, Concurrency Tool, Q1 2017—Q1 2022, United States, data extracted April 2022. The nationally projected number of patients that filled a concurrent statin and proprotein convertase subtilisin kexin 9 (PCSK9) inhibitor from US outpatient retail pharmacies (excluding dental, veterinary, and naturopath specialty prescribers), stratified by statin intensity. Dots represent when there was a statistically significant change in slope from joinpoint regression. In April 2019, the FDA broadened the indications for the PCSK9 inhibitor alirocumab to include secondary event prevention among patients with established cardiovascular disease. FDA = Food and Drug Administration, PCSK9 inhibitor = proprotein convertase subtilisin kexin 9

Figure 1.

Total projected numbers of patients filling any PCSK9 inhibitor, ezetimibe, or statin, Q1 2017‒Q1 2022. Notes: IQVIA Total Patient Tracker, Q1 2017‒Q1 2022, U.S., data extracted April 2022. The nationally projected numbers of patients that filled any statin (represented by the dotted line on the secondary axis), ezetimibe, and proprotein convertase subtilisin kexin 9 (PCSK9) inhibitor (represented by the solid lines on the primary axis) from an outpatient retail pharmacy (excluding dental, veterinary, and naturopath specialty prescribers) regardless of concurrency. Dots represent when there was a statistically significant change in slope from joinpoint regression. There were no statistically significant changes in slope for statins.

Figure 2.

Projected number of patients filling a statin alone from outpatient retail pharmacies, overall and stratified by statin intensity, Q1 2017–Q1 2022. Notes: IQVIA Total Patient Tracker, Concurrency Tool, Q1 2017‒Q1 2022, U.S., data extracted April 2022. The nationally projected number of patients that filled only a statin as a form of lipid-lowering medication (among statins, ezetimibe, and PCSK9 inhibitors) from U.S. outpatient retail pharmacies (excluding dental, veterinary, and naturopath specialty prescribers), stratified by statin intensity. Patient counts are estimates for each period and should not be summed, at the risk of double-counting patients who filled multiple products or appear in multiple time periods or multiple intensities during the times evaluated.

Figure 3.

Projected number of patients filling concurrent statin and ezetimibe from outpatient retail pharmacies, stratified by statin intensity, Q1 2017‒Q1 2022. Notes: IQVIA Total Patient Tracker, Concurrency Tool, Q1 2017‒Q1 2022, U.S., data extracted April 2022. The nationally projected number of patients that filled a concurrent statin and ezetimibe from U.S. outpatient retail pharmacies (excluding dental, veterinary, and naturopath specialty prescribers), stratified by statin intensity. Dots represent when there was a statistically significant change in slope from joinpoint regression.

Figure 4.

Projected number of patients filling concurrent statin, ezetimibe, and PCSK9 inhibitor from outpatient retail pharmacies, stratified by statin intensity, Q1 2017‒Q1 2022. Notes: IQVIA Total Patient Tracker, Concurrency Tool, Q1 2017‒Q1 2022, U.S., data extracted April 2022. The nationally projected number of patients that filled a concurrent statin, ezetimibe, and PCSK9 inhibitor from U.S. outpatient retail pharmacies (excluding dental, veterinary, and naturopath specialty prescribers), stratified by statin intensity. Dots represent when there was a statistically significant change in slope from joinpoint regression. In April 2019, the FDA broadened the indications for the PCSK9 inhibitor alirocumab to include secondary event prevention among patients with established cardiovascular disease.