Enzitimibe

[epicandprivate]

According to a MKSAP question it is appropriate to add enzitmibe to a patient who's already taking atorvastatin for reduction of cardiovascular risk (in a patient with recent ACS). They reference IMPROVE-IT trial. But in this study pts got either simvastatin or simvastatin plus enzitimibe which is not really the standard of care for pts with history of ACS. Would you really add it to atorvastatin based on this study. Thoughts?

I feel like I would only add enzitimibe to simvastatin in this pt population if pt was intolerant to high intensity statin but tolerating simvastatin.

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[Rocher]

According to a MKSAP question it is appropriate to add enzitmibe to a patient who's already taking atorvastatin for reduction of cardiovascular risk (in a patient with recent ACS). They reference IMPROVE-IT trial. But in this study pts got either simvastatin or simvastatin plus enzitimibe which is not really the standard of care for pts with history of ACS. Would you really add it to atorvastatin based on this study. Thoughts?

I feel like I would only add enzitimibe to simvastatin in this pt population if pt was intolerant to high intensity statin but tolerating simvastatin.

The only time I've added it (and mind you I'm a resident) is when high-risk patients are on maximal statin therapy and are not achieving LDL goal <70 or as you alluded to are intolerant to high intensity statins. I realize that IMPROVE-IT used simvastatin but at my institution we add ezetimibe to atorvastatin.

 

[Instatewaiter]

The only time I've added it (and mind you I'm a resident) is when high-risk patients are on maximal statin therapy and are not achieving LDL goal <70 or as you alluded to are intolerant to high intensity statins. I realize that IMPROVE-IT used simvastatin but at my institution we add ezetimibe to atorvastatin.

I rarely use it and let me tell you why:
First, Ezetimibe is a fortune depending on insurance. Medicare does cover it but it is something like $35. Other insurances don't cover it and patients have to fork over >$100. For no reduction in death, not worth it. Medicare patients would have to spend almost $3500 for a 1 in 60 chance of preventing 1 non-fatal MI or stroke Doesn't seem worth it.

Second they used a relatively weak statin Simva. Simva 80 is equivalent to 10-20 of rosuva. Most importantly, only 27% of patients in the control group got to high dose simvastatin

Third, there is no difference in mortality. It is a difference in a composite endpoint.

Finally, in the trial at 6 years, 42% discontinued the study medications ...

Were it a $4 drug, I would probably use it. But when someone comes into my unit with a STEMI they're going home on ASA/Brilinta, Metop, Atorva +/- ACE +/- MRA so adding another med will probably decrease compliance with the things that will save lives. NNT for a statin after an MI (to save a life) is about the same as the NNT for the composite outcome with Ezetimibe (with no reduction in death).

 

[nlax30]

During general fellowship we rarely used it and had very similar opinions as was mentioned above.

If someone came to us on it then fine, wouldn't change it but I can think of maybe only 1 or 2 instances where I actually started it on someone.

 

[epicandprivate]

I rarely use it and let me tell you why:
First, Ezetimibe is a fortune depending on insurance. Medicare does cover it but it is something like $35. Other insurances don't cover it and patients have to fork over >$100. For no reduction in death, not worth it. Medicare patients would have to spend almost $3500 for a 1 in 60 chance of preventing 1 non-fatal MI or stroke Doesn't seem worth it.

Second they used a relatively weak statin Simva. Simva 80 is equivalent to 10-20 of rosuva. Most importantly, only 27% of patients in the control group got to high dose simvastatin

Third, there is no difference in mortality. It is a difference in a composite endpoint.

Finally, in the trial at 6 years, 42% discontinued the study medications ...

Were it a $4 drug, I would probably use it. But when someone comes into my unit with a STEMI they're going home on ASA/Brilinta, Metop, Atorva +/- ACE +/- MRA so adding another med will probably decrease compliance with the things that will save lives. NNT for a statin after an MI (to save a life) is about the same as the NNT for the composite outcome with Ezetimibe (with no reduction in death).

I hadn't considered the price as a factor but that's a good point. Is it really worth the wallet biopsy if it's not saving life's.