Money, money, money

In 2009, around £73.5million was spent on the lipid-regulating drug ezetimibe in England (plus around another £10million on the combination product simvastatin plus ezetimibe) out of a total primary care prescribing spend of £8.5billion. By comparison, just £10million was spent on the drug in 2004. This increase (mirrored throughout the UK) contrasts with a fall in overall expenditure on (but increased prescribing of) lipid-regulating drugs, particularly generic simvastatin (e.g. from around £769million to £566million in England). So is the investment in ezetimibe a rational use of NHS resources?

The evidence on effectiveness for ezetimibe is based largely on surrogate outcomes, particularly cholesterol concentrations. There are no published data to show it reduces mortality or morbidity.1 Despite this, it is often used with a statin to achieve a greater reduction in cholesterol concentrations. Recent safety warnings about simvastatin 80mg daily2 may further encourage such practice. However, the case for intensifying lipid-lowering treatment to pursue population-wide cholesterol targets lacks evidence and is controversial. Even leaving this aside, there is no sound basis for the growing use of ezetimibe. The National Institute for Health and Clinical Excellence advises that for secondary prevention in patients without acute coronary syndrome, clinicians should “consider increasing to simvastatin 80mg or a drug of similar efficacy and acquisition cost if a total cholesterol of less than 4mmol/litre or an LDL cholesterol of less than 2mmol/litre is not attained.”3 Ezetimibe is neither of similar efficacy nor similar acquisition cost to simvastatin 80mg daily. So it is questionable whether adding ezetimibe to simvastatin is a cost-effective or outcome-based intervention. Since it is proving increasingly expensive for the NHS, prescribers should ask why they are using the drug.

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