TREATING HYPERLIPIDEMIA FOR THE PRIMARY PREVENTION OF CORONARY-DISEASE - ARE HIGHER DOSAGES OF LOVASTATIN COST-EFFECTIVE

Objective: To compare the average and marginal lifetime cost-effective ness of increasing dosages of 3-hydroxy-3-methylglutaryl coenzyme A (H MG-CoA) reductase inhibitors, such as lovastatin, for the primary prev ention of coronary heart disease (CHD). Methods: We estimated the life long costs and benefits of the modification of lipid levels achieved w ith lovastatin based on published studies and a validated CHD preventi on 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 mmo l/L (258, 303, and 383 mg/dL), and high-density lipoprotein cholestero l levels of 1.19 mmol/L (46 mg/dL), as described in clinical trials. W e 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 be tween 17% and 34%, and increased high-density lipoprotein cholesterol level between 4% and 13%. Results: After discounting benefits and cost s by 5% annually, the average cost-effectiveness of lovastatin, 20 mg/ d, ranged from $11 040 to $52 463 for men and women. The marginal cost -effectiveness of 40 mg/d vs 20 mg/d remained in this range ($25 711 t o $60 778) only for persons with baseline total cholesterol levels of 7.84 mmol/L (303 mg/dL) or higher. However, the marginal cost-effectiv eness of lovastatin, 80 mg/d vs 40 mg/d, was prohibitively expensive ( $99 233 to $716 433 per year of life saved) for men and women, irrespe ctive of the baseline total cholesterol level. Conclusions: Assuming t hat $50 000 per year of life saved is an acceptable cost-effectiveness ratio, treatment with lovastatin at a dosage of 20 mg/d is cost-effec tive for middle-aged men and women with baseline total cholesterol lev els of 6.67 mmol/L (258 mg/dL) or higher. At current drug prices, trea tment 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.