Thursday, January 01, 2015

More Pills!!! More Pills???

A new study called the IMPROVE-IT trial presented at the American Heart Association Scientific Sessions in November demonstrated that adding ezetimibe (Zetia) to simvastatin in higher-risk patients is associated with a decrease in LDL cholesterol and also decreased risk of cardiac events.

Another study, the TRA2P-TIMI 50 trial, found that a new antiplatelet medicine vorapaxar (Zontivity), when added to aspirin and clopidogrel (Plavix), reduces the risk of cardiac events in high-risk patients.

First off, two big wins for big pharma.  Two on-patent, in other words not generic, medicines that have positive clinical outcomes.  But, should we start prescribing them widely?

In the IMPROVE-IT trial, the primary endpoint of cardiac events occurred in 32.7% of patients on simvastatin alone and in 34.7% of patients on simvastatin plus ezetimibe.  It comes out to an absolute risk reduction of 2%, which isn't a lot.  In other words, to prevent a single cardiovascular event, you would have to give ezetimibe to 50 people over the course of six years.  That also means that 49 of 50 people receiving the medication would not have an event prevented.

Similarly, in TRA2P-TIMI 50, patients taking vorapaxar had an 11.2% risk of cardiovascular events, and those not taking it had a 12.4% risk.  Again, a statistically significant difference, but a 1.2% absolute risk reduction, and yields a number needed to treat of 83.  83 patients need to get a daily pill over three years to prevent just one event.  And if you're on vorapaxar, you will have a significantly increased risk of a dangerous bleed.

I want to give my patients everything that I can to keep them healthy.  But do I want to give them more costly copays?  Is that where my energy should be focused, putting my patients on more medications?
source:  reason.com

What if we can get these patients to change their lifestyle?  What if we can get them onto plant-based diets, get them walking 30 minutes a day, help them to lose weight, and get those who are smoking to quit?  How many cardiovascular events can we prevent if we can do that -- a lot!

Or more practically, since we know not all patients are so motivated, let's say we can get our patients to eat less meat and dairy, eat a few more fruits and vegetables a day, eat more meals at home instead of at restaurants, and walk a couple days a week.  Even with those more modest lifestyle, we can prevent a lot of heart attacks and strokes.

Is there a role for these two medicines, ezetimibe and vorapaxar?  Maybe.  But before we pull out our prescription pads, let's make sure we're giving our patients all of the tools that they need to be healthy, not just another pill.

2 comments:

Tony Bisceglia said...

There is hope!!
https://www.yahoo.com/health/new-diet-guidelines-might-pull-back-from-meat-106931992162.html

PGYx said...

What if we can get these patients to change their lifestyle? What if we can get them onto plant-based diets, get them walking 30 minutes a day, help them to lose weight, and get those who are smoking to quit? How many cardiovascular events can we prevent if we can do that -- a lot!

Or more practically, since we know not all patients are so motivated, let's say we can get our patients to eat less meat and dairy, eat a few more fruits and vegetables a day, eat more meals at home instead of at restaurants, and walk a couple days a week. Even with those more modest lifestyle, we can prevent a lot of heart attacks and strokes.


Amen! Why don't we make prevention our top priority? Most folks would rather never get the disease in the first place, but our medical system focuses on treating existing disease, which costs more money and offers a lot less benefit than prevention.

Preventive strategies are mostly low- or no-cost, so why don't we use them more? I'd really like to know the true reasons so we can address them.