When the FOURIER trial was published in 2017, cardiologists and lipidologists everywhere hailed it as proof that lowering LDL with PCSK9 inhibitors “saves lives.” But when you actually read the data, not the press releases, it’s hard not to shake your head.
Over a median of 2.2 years, evolocumab (Repatha) reduced nonfatal heart attacks by about 0.9 percent and had no significant impact on death. The absolute risk reduction for all-cause mortality was 0.1 percent. That means we’d have to treat 1,000 people for over two years to save one life. At today’s discounted price of around $6,000 per year, that’s $12.9 million per life saved. Using pre-cut list prices, it’s over $30 million. Even if you assume that person lives another 15 years, that’s $860,000 per life-year gained, which is about 10 times the usual threshold for cost-effectiveness in medicine. And that’s before adding the cost of all the blood draws, prior authorizations, and patient frustration.
If I were running an insurance company or a national health service, I wouldn’t pay for it either. We’ve reached a point where we celebrate statistical significance while ignoring economic nonsense. We’re spending millions to slightly reduce the probability of a nonfatal event in already well-treated patients.
I’m a lipidologist, or as I like to call myself now, a “lipidologist in recovery.” I’ve lived through the HDL delusion, the niacin fiasco, and now the PCSK9 era. Each time, the story is the same: impressive relative risk reductions that vanish when translated into absolute benefit and cost per life saved.
We need to start telling our patients and our policymakers the truth: Some therapies make biochemical sense but financial insanity. Until prices drop by 80 percent or we find a subgroup where the risk is truly off the charts, PCSK9 inhibitors remain a great molecule and a terrible investment.
And yet, I’ll probably still get an email tomorrow from a drug rep inviting me to a dinner program about how Repatha is “changing the trajectory of cardiovascular disease.” I suppose it is, mainly the trajectory of health care spending.
Larry Kaskel is an internist and “lipidologist in recovery” who has been practicing medicine for more than thirty-five years. He operates a concierge practice in the Chicago area and serves on the teaching faculty at the Northwestern University Feinberg School of Medicine. In addition, he is affiliated with Northwestern Lake Forest Hospital.
Before podcasts entered mainstream culture, Dr. Kaskel hosted Lipid Luminations on ReachMD, where he produced a library of more than four hundred programs featuring leading voices in cardiology, lipidology, and preventive medicine.
He is the author of Dr. Kaskel’s Living in Wellness, Volume One: Let Food Be Thy Medicine, works that combine evidence-based medical practice with accessible strategies for improving healthspan. His current projects focus on reevaluating the cholesterol hypothesis and investigating the infectious origins of atherosclerosis. More information is available at larrykaskel.com.
