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Treating Hyperlipidemia for the Primary Prevention of Coronary Disease
Are Higher Dosages of Lovastatin Cost-effective?
Sylvie Perreault, PhD;
Vivian H. Hamilton, PhD;
Frédéric Lavoie, MSc;
Steven A. Grover, MD, MPA, FRCPC
Arch Intern Med. 1998;158:375-381.
Objective To compare the average and marginal lifetime cost-effectiveness of increasing dosages of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, such as lovastatin, for the primary prevention of coronary heart disease (CHD).
Methods We estimated the lifelong costs and benefits of the modification of lipid levels achieved with lovastatin based on published studies and a validated CHD prevention computer model. Patients were middle-aged men and women without CHD, with mean total serum cholesterol levels of 6.67, 7.84, and 9.90 mmol/L (258, 303, and 383 mg/dL), and high-density lipoprotein cholesterol levels of 1.19 mmol/L (46 mg/dL), as described in clinical trials. We estimated the cost per year of life saved for dosages of lovastatin ranging from 20 to 80 mg/d that reduced the total cholesterol level between 17% and 34%, and increased high-density lipoprotein cholesterol level between 4% and 13%.
Results After discounting benefits and costs by 5% annually, the average cost-effectiveness of lovastatin, 20 mg/d, ranged from $11040 to $52463 for men and women. The marginal cost-effectiveness of 40 mg/d vs 20 mg/d remained in this range ($25711 to $60778) only for persons with baseline total cholesterol levels of 7.84 mmol/L (303 mg/dL) or higher. However, the marginal cost-effectiveness of lovastatin, 80 mg/d vs 40 mg/d, was prohibitively expensive ($99233 to $716433 per year of life saved) for men and women, irrespective of the baseline total cholesterol level.
Conclusions Assuming that $50000 per year of life saved is an acceptable cost-effectiveness ratio, treatment with lovastatin at a dosage of 20 mg/d is cost-effective for middle-aged men and women with baseline total cholesterol levels of 6.67 mmol/L (258 mg/dL) or higher. At current drug prices, treatment with 40 mg/d is also cost-effective for total cholesterol levels of 7.84 mmol/L (303 mg/dL) or higher. However, treatment with 80 mg/d is not cost-effective for primary prevention of CHD.
From the Centre for the Analysis of Cost-Effective Care and the Division of Clinical Epidemiology, The Montreal General Hospital (Drs Perreault, Hamilton, and Grover and Mr Lavoie), and the Departments of Medicine (Drs Hamilton and Grover) and Epidemiology and Biostatistics (Dr Grover), McGill University, Montreal, Quebec; and the John M. Olin School of Business, Washington University, St Louis, Mo (Dr Hamilton).
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