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Purpose: The statins are among the most frequently prescribed prescription drugs. Their appropriate use is essential for both quality of care and control of prescription drug costs. Managed care companies have encouraged clinicians to prescribe lovastatin (available generically) as the statin of first choice. The goal of this study was to determine if this policy is consistent with optimal use of statins in clinical practice.
Methods: A multi-criteria decision analysis was performed using the Analytic Hierarchy Process based on the STEP approach -Safety, Tolerability, Effectiveness, Price - to comparing different pharmaceutical agents. (BMJ. 1996;312:1494) Data were obtained from the literature regarding the safety, tolerability, and effectiveness of the initial doses of the 6 statins currently available in the US: atorvastatin (A), fluvastatin (F), lovastatin (L), pravastatin (P), rosuvastatin (R), and simvastatin (S). Prices were obtained from a 3-tier formulary used by a managed care organization that recommends first line use of lovastatin. This formulary divides drugs into 3 categories, with patient co-payments of $5 for each prescription of lovastatin, $20 for atorvastatin or pravastatin, and $35 for fluvastatin, rosuvastatin, or simvastatin. All statins are believed to be equally tolerable, so this criterion was removed from the analysis. Effectiveness was divided into LDL-C lowering and proven patient outcomes; LDL lowering was considered much more important. Safety was subdivided into 3 equally important sub-criteria: proven long term safety, minimal renal dose adjustments, and low potential for drug-drug interactions.
Results: If Safety, Effectiveness, and Price are considered equally important (priorities all equal to 0.33), lovastatin is the drug of choice (L 21.4%; A 18.5%; P 18.2%; R 14.3%; F 13.8%, S 13.8%) Sensitivity analysis shows that lovastatin is the drug of choice if its priority is: ≥0.21 if Effectiveness and Safety are considered equally important, ≥0.195 if Effectiveness is considered twice as important as Safety, and ≥0.23 if Safety is considered twice as important as Effectiveness.
Conclusions: Advice to prescribe lovastatin as the statin of first choice is reasonable as long as patient out-of-pocket cost is given a priority of at least 20% relative to Effectiveness and Safety. Routine assessment and incorporation of patient priorities regarding these criteria would help both maintain quality of care and effectively manage pharmaceutical costs.
See more of Poster Session - Clinical Strategies; Judgment and Decison Making
See more of The 26th Annual Meeting of the Society for Medical Decision Making (October 17-20, 2004)