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Updated: Jun 14, 2025
Cholesterol Efflux Assay
Published on: March 6, 2012
Rethinking cardiovascular prevention: cost-effective cholesterol lowering for statin-intolerant patients in Australia
Jedidiah I Morton1,2, Danny Liew3, Gerald F Watts4,5
1Health Economics and Policy Evaluation Research (HEPER) Group, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC 3052, Australia.
Insights
Ezetimibe and bempedoic acid are cost-effective for preventing cardiovascular disease (CVD) in statin-intolerant individuals. Early intervention with these non-statin drugs offers a viable primary prevention strategy based on individual risk factors.
Area of Science:
- Cardiovascular Disease Prevention
- Health Economics
- Pharmacoeconomics
Background:
- Approximately 9% of the population experiences statin intolerance.
- No prior studies have assessed the cost-effectiveness of early primary prevention of cardiovascular disease (CVD) using non-statin therapies.
- This study evaluates three non-statin options: ezetimibe, proprotein convertase subtilisin-kexin type 9 inhibitors (PCSK9i), and bempedoic acid.
Purpose of the Study:
- To determine the cost-effectiveness of initiating non-statin lipid-lowering therapies at age 40 for primary CVD prevention.
- To compare the cost-effectiveness of ezetimibe, PCSK9i (inclisiran, evolocumab), and bempedoic acid against established thresholds in Australia and the UK.
Main Methods:
- A microsimulation model with 108 statin-intolerant individuals aged 40-85 years was utilized.
- Incremental cost-effectiveness ratios (ICERs) were calculated for non-statin interventions initiated at age 40 versus no intervention.
- Analyses were conducted from the perspective of the Australian and UK national healthcare systems, with country-specific cost-effectiveness thresholds and discounting rates.
Main Results:
- In Australia, ezetimibe was cost-effective in 31.4% of individuals, bempedoic acid in 15.7%, and their combination in 13.0%. PCSK9 inhibitors were not cost-effective.
- In the UK, ezetimibe was cost-effective in 90.7% of individuals, bempedoic acid in 4.6%, and their combination in 10.2%. PCSK9 inhibitors were not cost-effective.
- Bempedoic acid's cost-effectiveness was linked to specific baseline LDL-C and systolic blood pressure thresholds, varying between Australia and the UK.
Conclusions:
- Ezetimibe and bempedoic acid, individually or in combination, demonstrate cost-effectiveness for long-term primary CVD prevention in statin-intolerant populations.
- The decision to use these non-statin therapies should be guided by an individual's baseline cardiovascular risk profile.
- These findings support the use of specific non-statin agents as a cost-effective alternative for primary CVD prevention in statin-intolerant patients.
Aims:
Approximately 1 in 11 people are intolerant to statins. There have been no studies evaluating the cost-effectiveness of early intervention for primary prevention of cardiovascular disease (CVD) with three non-statin drugs [ezetimibe, proprotein convertase subtilisin-kexin type 9 inhibitors (PCSK9i; inclisiran and evolocumab), and bempedoic acid]. We aimed to evaluate the cost-effectiveness of these therapies when initiated at age 40 years.
Methods And Results:
We used a published microsimulation model populated with 108 statin-intolerant individuals. The model simulated the ageing of individuals from 40 to 85 years. We calculated the incremental cost-effectiveness ratio when non-statin lipid-lowering strategies were initiated at age 40 years compared to no intervention until a cardiovascular event. Incremental cost-effectiveness ratios were compared to Australian and UK cost-effectiveness thresholds of 28 000 AUD and 25 000 GBP per quality adjusted life year gained, respectively. We adopted each countries national healthcare system perspective (2022 AUD/GBP) and discounted health economic results by 5% annually for Australia and 3.5% annually for the UK. At current prices in Australia, ezetimibe was cost-effective in 34/108 (31.4%) individuals simulated; bempedoic acid in 17/108 (15.7%); bempedoic acid and ezetimibe in combination in 14/108 (13.0%); while inclisiran and evolocumab were not cost-effective in any individuals. Corresponding numbers for the UK were 98/108 (90.7%); 5/108 (4.6%); 11/108 (10.2%); 0/108 (0.0%); and 0/108 (0.0%). Cost-effectiveness of bempedoic acid was predominantly among individuals with an LDL-C of at least 4.0 mmol/L and systolic blood pressure of at least 140 mmHg in Australia and 5.0 mmol/L and 160 mmHg in the UK, respectively.
Conclusion:
Ezetimibe and bempedoic acid, both alone and in combination, are cost-effective for long-term primary prevention of CVD in a range of people with statin intolerance, depending on their baseline risk of CVD.
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