School of Health & Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, UK.
Eur J Prev Cardiol. 2012 Jun;19(3):474-83. doi: 10.1177/1741826711406616. Epub 2011 Apr 1.
While evidence shows high-dose statins reduce cardiovascular events compared with moderate doses in individuals with acute coronary syndrome (ACS), many primary care trusts (PCT) advocate the use of generic simvastatin 40 mg/day for these patients.
Data from 28 RCTs were synthesized using a mixed treatment comparison model. A Markov model was used to evaluate the cost-effectiveness of treatments taking into account adherence and the likely reduction in cost for atorvastatin when the patent expires. There is a clear dose-response: rosuvastatin 40 mg/day produces the greatest reduction in low-density lipoprotein cholesterol (56%) followed by atorvastatin 80 mg/day (52%), and simvastatin 40 mg/day (37%). Using a threshold of £20,000 per QALY, if adherence levels in general practice are similar to those observed in RCTs, all three higher dose statins would be considered cost-effective compared to simvastatin 40 mg/day. Using the net benefits of the treatments, rosuvastatin 40 mg/day is estimated to be the most cost-effective alternative. If the cost of atorvastatin reduces in line with that observed for simvastatin, atorvastatin 80 mg/day is estimated to be the most cost-effective alternative.
Our analyses show that current PCT policies intended to minimize primary care drug acquisition costs result in suboptimal care.
虽然有证据表明高剂量他汀类药物与急性冠脉综合征（ACS）患者的中等剂量相比能降低心血管事件，但许多初级保健信托基金（PCT）主张为这些患者使用通用辛伐他汀 40mg/天。
使用混合治疗比较模型综合了 28 项 RCT 的数据。采用马尔可夫模型来评估治疗的成本效益，同时考虑到依从性以及专利到期时阿托伐他汀成本可能降低的情况。存在明确的剂量反应关系：每天服用 40mg 瑞舒伐他汀可使低密度脂蛋白胆固醇降低 56%，其次是每天服用 80mg 阿托伐他汀（降低 52%）和每天服用 40mg 辛伐他汀（降低 37%）。如果使用每 QALY 20,000 英镑的阈值，如果一般实践中的依从水平与 RCT 中观察到的水平相似，那么与辛伐他汀 40mg/天相比，所有三种高剂量他汀类药物都被认为是具有成本效益的。使用治疗的净效益，每天服用 40mg 瑞舒伐他汀被估计为最具成本效益的替代药物。如果阿托伐他汀的成本降低与辛伐他汀观察到的情况一致，则每天服用 80mg 阿托伐他汀被估计为最具成本效益的替代药物。
我们的分析表明，目前旨在尽量降低初级保健药物获取成本的 PCT 政策导致了次优的护理。
