OBJECTIVES: Non-statin lipid-modifying agents provide additional benefits for cardiovascular disease (CVD) risk reduction when added to statin therapy, but their value for money has only been evaluated in high-income countries (HICs). Our study aimed to assess the cost-effectiveness of non-statin agents in statin-treated patients who have history of CVD using data from the most recent network meta-analysis (NMA) and local parameters.

METHODS: A published Markov model was adopted to investigate lifetime outcomes: (1) number of recurrent CVD events prevented, (2) quality-adjusted life years (QALYs) gained, (3) costs and (4) incremental cost-effectiveness ratios (ICERs) of proprotein convertase subtilisink/kexin type 9 inhibitor (PCSK9i) and ezetimibe added to statin therapy. Event rates and effectiveness inputs were obtained from the NMA comparing non-statin agents among statin-treated patients. Cost and utility data were gathered from published studies conducted in Thailand. A series of sensitivity analyses were performed.

RESULTS: Based on the NMA of 67 randomized controlled trials for the secondary prevention of CVD, no interventions had significant treatment effects on any mortality. However, PCSK9i plus statin significantly reduced the risk of non-fatal CVD [relative risk (RR): 0.79; 95% confidence interval (95% CI): 0.72-0.96], compared to statin alone. For economic evaluation under the societal perspective, patients receiving PCSK9i and ezetimibe experienced less recurrent CVD events [number-needed to treat (NNT): 17 and 30] and more QALYs (0.168 and 0.096 QALYs gained per person). However, at current acquisition costs, ICERs of both agents were 1,223,995 and 27,361 US$/QALY gained, respectively. Based on threshold analyses, treatment costs need to be reduced by 97% and 85% for PCSK9i and ezetimibe to be cost-effective.

CONCLUSIONS: Despite the clearly demonstrated effectiveness of PCSK9i and ezetimibe, their costs need to be reduced in much greater extent than HICs to become cost-effective in Thailand.