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. 2026 Feb;115(2):266-276.
doi: 10.1007/s00392-025-02686-5. Epub 2025 May 28.

Treatment pathways of lipid-lowering therapies in Germany 2016-2022

Julius L Katzmann  1 , Claudia Grellmann  2 , Beate Leppert  3 , Irina Müller-Kozarez  4 , Martin Schulz  5   6 , Ulrich Laufs  4
Affiliations

Treatment pathways of lipid-lowering therapies in Germany 2016-2022

Julius L Katzmann et al. Clin Res Cardiol. 2026 Feb.

Abstract

Background: Despite the availability of effective LDL cholesterol (LDL-C)-lowering drugs, only a minority of patients achieves the guideline-recommended treatment targets. This analysis describes treatment pathways of lipid-lowering therapy (LLT) in Germany.

Methods: Health claims data were used to identify patients at high or very-high cardiovascular risk who received a LLT prescription 2016-2022. Treatment pathways and the time to switch or discontinue LLT were analysed for statins, ezetimibe, bempedoic acid (BA), and PCSK9 inhibitors (PCSK9i).

Results: Out of 3,487,827 insured persons, 247,529 met the inclusion criteria. The most frequent first-line LLT were statins in 96.3%. Ezetimibe, BA, and PCSK9i were first-line LLT in only 0.9%, 0.061%, and 0.046%, respectively. Only few patients experienced a change in their treatment regimen following LLT initiation. Prescriptions of BA and PCSK9i were mainly second-, third-, or fourth-line add-on treatment. Termination of treatment with BA and PCSK9i was less frequent compared to statins and ezetimibe. The median time to treatment discontinuation was 1.45, 1.04, 0.60, and 2.45 years for statins, ezetimibe, BA, and PCSK9i, respectively, and the median time to switch therapy was 4.81 and 4.87 years for ezetimibe and PCSK9i, respectively (median not reached for statins and BA).

Conclusions: Changes in LLT were only observed in a minority of patients. BA and PCSK9i were switched more frequently than statins and ezetimibe. BA was discontinued earlier, and PCSK9i later than the other agents. Continued efforts to maintain long-term adherence and overcome therapeutic inertia are needed to realise the potential of available LLT with proven cardiovascular benefit.

Keywords: Bempedoic acid; Ezetimibe; PCSK9 inhibitor; Statin; Therapeutic inertia.

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Conflict of interest statement

Declarations. Conflict of interest: JLK: honoraria and travel grants from Daiichi Sankyo, honoraria from Novartis, honoraria from Synlab, travel grants from Lilly and Boehringer Ingelheim. CG: employed at Institute for Applied Health Services Research GmbH (inav) and paid consultant of Daiichi Sankyo for designing the study and carrying out the analyses. BL: employed at Gesundheitsforen Leipzig GmbH and paid consultant of Daiichi Sankyo for designing the study and carrying out the analyses. IMK: honoraria from Daiichi Sankyo, Sobi, Astra Zeneca. MS: honoraria from BMS, Daiichi Sankyo, Novartis, Pfizer, TAD, CSL Vifor. UL: honoraria from Amgen, Daiichi Sankyo, Novartis, and Sanofi.

Figures

Fig. 1
Fig. 1
Flow chart of patient selection
Fig. 2
Fig. 2
Treatment pathways of all lipid-lowering therapies. N = 280,100 events of lipid-lowering therapy initiation were analysed, with double counting of patients with treatment gaps of at least one year. Rare index treatments affecting less than 1% of patients are summarized as “other rare treatment lines”, rare 2L + treatments affecting less than 0.5% of patients are summarized as “other rare 2L + treatment”. 1L, 2L, … first line, second line, …
Fig. 3
Fig. 3
Treatment pathways of lipid-lowering therapy involving bempedoic acid. N = 1862 events of lipid-lowering therapy initiation were analysed, with double counting of patients with treatment gaps of at least one year. Rare index treatments affecting less than 1% of patients are summarized as “Other rare treatment lines involving BA”, rare 2L + treatments affecting less than 2% of patients (about n < 10 in 2L) are summarized as “Other rare treatment lines (2L +) involving BA”. 1L, 2L, … first line, second line, …; BA bempedoic acid, PCSK9i PCSK9 inhibitor
Fig. 4
Fig. 4
Treatment pathways of lipid-lowering therapy involving PCSK9 inhibitors. N = 846 events of lipid-lowering therapy initiation were analysed, with double counting of patients with treatment gaps of at least one year. Rare index treatments affecting less than 1% of patients are summarized as “Other rare treatment lines involving PCSK9i”, rare 2L + treatments affecting less than 5 patients are summarized as “Other rare treatment lines (2L +) involving PCSK9i”. 1L, 2L, … first line, second line, …; BA bempedoic acid, PCSK9i PCSK9 inhibitor
Fig. 5
Fig. 5
Kaplan–Meier curves of time to switch lipid-lowering therapy
Fig. 6
Fig. 6
Kaplan–Meier curves of persistence to lipid-lowering therapy. Treatment persistence is defined as the probability of no treatment termination. Patients with treatment switch are excluded from this analysis
See this image and copyright information in PMC

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