Cost-effectiveness analysis of using atorvastatin, simvastatin, ezetimibe, alirocumab, evolocumab, inclisiran in adults with very high cardiovascular risk under the preferential drug provision program

Abstract

Objective: to evaluate the clinical and economic feasibility of expanding the preferential drug provision (PDP) program for adult patients at very high cardiovascular (CV) risk, including those who have not reached lipid targets on statin therapy, by increasing the frequency of use of ezetimibe, alirocumab, evolocumab and inclisiran used in combination with statins, compared with current PDP practice (use of atorvastatin, simvastatin and minimal use of other drugs).Material and methods. A Markov model was constructed to characterize the development of atherosclerotic heart disease in patients with very high CV risk and to suggest a consistent change in hypolipidemic therapy if it is ineffective. The model considered patients' compliance to drug therapy over time and the factor of non-prescription of any treatment. The modeling horizon was 30 years, and the model cycle was 1 year. The outcomes used were quality-adjusted life years (QALY), life years gained (LYG), and probabilities of various individual and combined CV events. The baseline modeling scenario was to increase the frequency of рroprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors’ prescriptions. In addition, alternative scenarios were modeled that included prescription of highly effective lipid-lowering therapy for all patients who had not reached target low-density lipoprotein cholesterol (LDL-C) on statin therapy, and the scenario with 100% compliance to statin therapy.Results. In comparison with current practice of treatment of patients with very high CV risk, clinical and economic modeling showed a decrease in the incidence of combined outcomes (combined CV events – by 8%, extended combined CV events – by 9%) and individual CV events (heart attack – by 4%, stroke – by 3%, unstable angina – by 2%, revascularization – by 3%) in the baseline scenario. In scenarios of prescribing PCSK9 inhibitors and inclisiran to all patients who have not reached target values of LDL-C on statin therapy, the frequency of individual events ranged from 4% to 8%. In the scenario, which also implies 100% drug compliance, the reduction was from 8% to 17% compared with current patient management practices, characterized by lower frequency of hypolipidemic drugs, including PCSK9 inhibitors and inclisiran. The incremental cost-effectiveness ratio (ICER) for QALY in the baseline scenario was 3,598,156 rubles, the ICER for LYG was 1,949,393 rubles. When comparing the ICER with willingness-to-pay (WTP) threshold in the Russian Federation (calculated as three times the gross domestic product per capita and in 2022 amounting to 2.8 million rubles per effect unit) the ICER for LYG did not exceed the WTP in all scenarios, while the ICER for QALY exceeded the WTP by 29–44%, depending on the realized scenario.Conclusion. Expanding the PDP program for high CV risk patients will have a positive impact on their quality of life and life expectancy, as well as significantly reduce the likelihood of acute CV events. Comparison of ICER with estimated WTP suggests that expansion of the PBP program is a cost-effective organizational technology according to LYG criterion, but not according to the QALY criterion.