From the Guidelines
Statins are typically prescribed before Repatha (evolocumab) for cholesterol management due to their established effectiveness, safety profile, and affordability, as well as the requirement by insurance companies to try and fail statin therapy before approving Repatha coverage. The most recent and highest quality study, published in 2024 1, supports the use of statins as first-line therapy, with the addition of ezetimibe or a PCSK9 inhibitor, such as Repatha, if the LDL cholesterol goal of <55 mg/dL is not achieved on maximum tolerated statin therapy. This approach is based on the observation that high-intensity statin therapy reduces cardiovascular event rates in high-risk individuals with established cardiovascular disease.
Some key points to consider when deciding between statins and Repatha include:
- Cost: Statins are significantly more affordable, with generic versions costing as little as $10 per month, compared to Repatha's price of approximately $5,000-$6,000 annually.
- Administration: Statins are taken orally once daily, while Repatha requires subcutaneous injections every two weeks or monthly.
- Mechanism of action: Statins work by inhibiting HMG-CoA reductase in the liver, blocking cholesterol production, while Repatha is a PCSK9 inhibitor that increases LDL receptor availability.
- Indications: Repatha is typically reserved for patients with familial hypercholesterolemia, those with established cardiovascular disease who need additional LDL lowering, or patients who cannot tolerate statins due to side effects like muscle pain, as recommended by the 2017 update of the ESC/EAS task force on practical clinical guidance for proprotein convertase subtilisin/kexin type 9 inhibition 1.
Overall, the decision to prescribe statins or Repatha should be based on individual patient needs and circumstances, taking into account the latest evidence and guidelines, such as those outlined in the 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction 1.
From the Research
Reasons for Prescribing Statins over Repatha
- Statins are well-established as the first-line treatment for reducing low-density-lipoprotein cholesterol (LDL-C) and cardiovascular (CV) events 2
- Statins have a long history of use and have proven their value in reducing cardiovascular events and mortality 3
- Repatha (evolocumab) is a more recent treatment option and is typically used as an adjunct to statin therapy or in patients who are unable to tolerate statins 4
Clinical Scenarios where Statins are Preferred
- Patients with no history of cardiovascular disease (CVD) may be started on statin monotherapy as primary prevention 5
- Patients at high or very high cardiovascular risk may be treated with an ezetimibe-statin combination to achieve a reduction of at least 50% in LDL-C levels 6
- Statins are often preferred in patients with specific conditions such as raised lipids, diabetes, hypertension, or microalbuminuria 5
Safety and Efficacy of Statins
- Statins have been shown to be safe and effective in reducing all-cause mortality, fatal and non-fatal CVD, and stroke events 5
- Statins have also been shown to reduce revascularization rates and improve patient quality of life 5
- While statins can cause adverse effects, the benefits of statin therapy are likely to outweigh the risks in most patients 3, 2