title: Cost effectiveness of ezetimibe in patients with cardiovascular disease and statin intolerance or contraindications: a Markov model.
abstract: OBJECTIVE
  To evaluate the cost effectiveness of long-term ezetimibe monotherapy in patients with established cardiovascular disease (CVD) who do not tolerate statins or in whom they are contraindicated.
  
  
  METHODS
  A Markov model was used to estimate the potential costs and benefits associated with ezetimibe monotherapy compared with no treatment. The benefits associated with ezetimibe treatment were informed by a systematic review of clinical evidence and a published relationship linking changes in low-density lipoprotein cholesterol (LDL-C) levels to cardiovascular events.
  
  
  RESULTS
  In the absence of data from clinical outcome trials, surrogate endpoints such as changes in lipid levels were used as indicators of clinical outcomes. A meta-analysis of seven placebo-controlled trials included in the review showed that ezetimibe was associated with a statistically significant mean reduction (from baseline to endpoint) in LDL-C of 18.56% (95% CI -19.68, -17.44; p < 0.00001) compared with placebo. Using 10,000 Monte Carlo simulations, it is estimated that ezetimibe monotherapy would prevent an average of 49 nonfatal myocardial infarctions, 11 nonfatal strokes, and 37 cardiovascular deaths in a cohort of 1,000 patients aged 55 years with a baseline LDL-C concentration of 4.0 mmol/L. Events avoided provide an additional 211 quality-adjusted life-years (QALYs) over the 45 years modeled. With a mean incremental cost of pound 4,861,000 (year 2006 value), the discounted cost per QALY is pound 23,026 (Jackknife CI 22 979, 23 074). The model is reasonably robust to variations in key parameters. Incremental cost-effectiveness ratios fall below pound 20,000 per QALY for cohorts with baseline LDL-C values >4.5 mmol/L.
  
  
  CONCLUSIONS
  Ezetimibe monotherapy compared with no treatment is a cost-effective alternative for individuals with a history of CVD and high LDL-C levels, who do not tolerate statins or in whom they are contraindicated.
authors.affiliation: Health Economics and Decision Science, ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK. r.m.ara@sheffield.ac.uk
authors.forename: Roberta
authors.initials: R
authors.lastname: Ara
authors.forename: Abdullah
authors.initials: A
authors.lastname: Pandor
authors.forename: Indra
authors.initials: I
authors.lastname: Tumur
authors.forename: Suzy
authors.initials: S
authors.lastname: Paisley
authors.forename: Alejandra
authors.initials: A
authors.lastname: Duenas
authors.forename: Robert
authors.initials: R
authors.lastname: Williams
authors.forename: Angie
authors.initials: A
authors.lastname: Rees
authors.forename: Anna
authors.initials: A
authors.lastname: Wilkinson
authors.forename: Paul
authors.initials: P
authors.lastname: Durrington
authors.forename: Jim
authors.initials: J
authors.lastname: Chilcott
mesh_terms: D000367:Age Factors; D000924:Anticholesteremic Agents / Q000191:economics* / Q000627:therapeutic use; D001384:Azetidines / Q000191:economics* / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000191:economics* / Q000209:etiology / Q000517:prevention & control*; D008078:Cholesterol, LDL / Q000097:blood; D015331:Cohort Studies; D000075202:Contraindications; D003362:Cost-Benefit Analysis; D000069438:Ezetimibe; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000009:adverse effects*; D006937:Hypercholesterolemia / Q000150:complications / Q000188:drug therapy / Q000191:economics; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D018803:Models, Economic; D019057:Quality-Adjusted Life Years; D006113:United Kingdom
chemical_list: D000924:Anticholesteremic Agents; D001384:Azetidines; D008078:Cholesterol, LDL; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D000069438:Ezetimibe