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To the Editor Dr Shrank and colleagues1 suggested that the advent of proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitors may mean reversion to a strategy of striving to achieve low-density lipoprotein cholesterol (LDL-C) goals. They indicated that such a strategy may be needed to avoid substantial drug costs. We disagree.
The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for treatment of cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) used an evidence-based approach that resulted in several changes in therapeutic strategy.2 One change was the focus on intensity of treatment rather than achievement of specific LDL-C goals as prior guidelines recommended.3 There were several reasons for this. First, the clinical trials were not designed to select LDL-C goals. Second, strict LDL-C goals can lead to addition of nonstatin drugs when the number needed to treat would be unacceptable in both costs and risks. Third, use of arbitrary goals may lead to undesirable down-titration of therapy in individuals at highest risk. Consider the patient with diabetes and acute coronary syndrome who achieves an LDL-C of 69 mg/dL with a moderate intensity statin. The Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) showed benefit from adding ezetimibe.4
Blum CB, Stone NJ. New Strategies to Treat High Cholesterol. JAMA. 2016;315(11):1169. doi:10.1001/jama.2015.18029