Which LDL‑C‑lowering medication is least expensive?

Statins are the Least Expensive LDL-C-Lowering Medication

Statins are generally inexpensive and easy to access, making them the least expensive option for LDL-C lowering, followed by ezetimibe at intermediate cost, with PCSK9 inhibitors being the most expensive. 1

Cost Hierarchy of LDL-C-Lowering Medications

The 2022 BMJ clinical practice guideline clearly establishes the following cost structure:

• Statins: Generally inexpensive and easy to access
• Ezetimibe: More expensive than statins but much cheaper than PCSK9 inhibitors and easy to access
• PCSK9 inhibitors: The most expensive drugs among lipid-lowering agents and not easy to access 1

Practical Considerations Beyond Acquisition Cost

PCSK9 Inhibitor Additional Costs

Beyond their prohibitive medication costs, PCSK9 inhibitors incur additional expenses:

• Require special storage and transportation at 2-8°C
• Need injection equipment
• Require special equipment for travel
• Limited availability in many countries, especially middle or low-income regions 1

Generic Availability

Both statins and ezetimibe are generically available worldwide, which substantially reduces their cost compared to branded PCSK9 inhibitors 1. This generic availability makes statins particularly cost-effective as first-line therapy.

Clinical Algorithm for Cost-Conscious Prescribing

1. Start with generic statins as first-line therapy (lowest cost)
2. Add ezetimibe if additional LDL-C lowering is needed (intermediate cost)
3. Reserve PCSK9 inhibitors for patients at very high cardiovascular risk who fail to reach targets with statin plus ezetimibe, recognizing the substantial cost burden 1

Important Caveat

The guideline panel explicitly states they did not consider medication costs when making clinical recommendations from the patient perspective, recognizing that for patients bearing medication costs directly, cost may prove decisive in treatment decisions 1. However, their recommendations align with cost-effectiveness concerns by favoring ezetimibe over PCSK9 inhibitors when additional lipid-lowering is needed beyond statins.