An injection to lower your cholesterol -PCSK9 inhibitors

 In Cardiology

A completely new generation of cholesterol lowering drugs is now being marketed. Evolocumab and alirocumab are a form of monoclonal antibodies that indirectly interfere with the LDL receptor resulting in huge reductions in blood cholesterol. They lower cholesterol by about 50% -as much as a high dose statin tablet. They also do this even if a statin has already been given.

The 3 main drawbacks are firstly that this drug needs to be given as an injection every 2 weeks. Secondly it costs currently well over £300 per month (compared to atorvastatin 80mg which is equally efficacious and costs about £2 a month). Thirdly there is no hard outcome data – we haven’t shown that it reduces heart attacks and strokes. We only know it reduces cholesterol effectively. We have seen other drugs which in theory should result in fewer cardiovascular events cause more due to other actions of the drug. This has been shown most spectacularly in drugs that elevate the good cholesterol in the body (HDL) eg torcetrapid and yet increase your chance of having a heart attack. We think this is because it has a small blood pressure elevating effect. We need to wait for the 2 main trials ODYSSEY and FOURIER to publish to see if PCSK-9 inhibitors actually give a meaningful benefit in terms of reducing cardiovascular events.

When I initially looked at these agents I thought there would only be a very small market for them. However the drug companies are no fools and they will carefully analyze potential benefits in relation to the drug and present to the government (NICE – national institute of clinical excellence) compelling statistics to say why they should be given prescribed freely.

There are some patients where it is vital to lower the cholesterol. These are the patients who have familial homozygous hypercholesterolaemia. These people develop premature coronary artery disease often having a myocardial infarction in their teenage years due to the cholesterol build up in their arteries. Unfortunately this group of patients have fewer LDL receptors for the drug to work on so does not seem to be as potent as in other patients.

How unreasonable is it to have an injection? Some diabetics inject themselves with insulin four times a day so is once a fortnight such a problem? We now can even give contraception in an injection every 3 months instead of in a pill so perhaps the UK public are not so squeamish about injections as I thought.

Would you have an injection every 2 weeks rather than taking tablets on a daily basis?

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