What’s the point of Ezetimibe?

MeReC

http://www.npc.co.uk/ebt/merec/cardio/cdlipids/merec_extra_no47.html

Why are we prescribing it?

• £85 million a year in primary care in England up to June 2010

• Does this represent good value for money and rational expenditure?

MeReC’s advice is that we should review, and where appropriate, revise prescribing of ezetimibe to ensure it is in line with NICE guidance

Quick reminder of NICE guidance…

• First line for primary prevention or secondary prevention should be simvastatin 40 mg

• For secondary prevention (without acute coronary syndrome) simvastatin can be increased to 80 mg in those patients with a cholesterol > 4 mmol/L and an LDL > 2 mmol/L

Ezetimibe is recommended as an option only in the following circumstances

• Where statins are contraindicated or not tolerated • In conjunction with a statin where serum total or LDL

cholesterol is not appropriately controlled (after appropriate dose titration)

What’s the problem with using ezetimibe routinely with simvastatin?

• Cost increases considerably • No evidence that adding in ezetimibe improves

outcomes. • Evidence for the efficacy of ezetimibe is based on

surrogate outcomes (i.e. lowering cholesterol), not on the drug itself.

• No evidence of any improved tolerability over simvastatin 80 mg or other NICE-recommended statins.  

• We rarely use other cholesterol-lowering meds now (because of lack of evidence base), so why use ezetimibe?