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Original Investigation |

Trends in Use of Ezetimibe After the ENHANCE Trial, 2007 Through 2010

Joseph S. Ross, MD, MHS1,2,3,4; Sharon G. Frazee, PhD, MPH5; Susan B. Garavaglia, PhD, MBA5; Rebecca Levin, MPH5; Haik Novshadian, BS5; Cynthia A. Jackevicius, PharmD, MSc6,7; Glen Stettin, MD5; Harlan M. Krumholz, MD, SM2,3,4,8
[+] Author Affiliations
1Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
2Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
3Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale School of Public Health, New Haven, Connecticut
4Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
5Division of Research and New Solutions, Express Scripts Inc, St Louis, Missouri
6Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Los Angeles, California
7Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
8Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
JAMA Intern Med. 2014;174(9):1486-1493. doi:10.1001/jamainternmed.2014.3404.
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Importance  Results from the Ezetimibe and Simvastatin in Hypercholesterolemia Enhances Atherosclerosis Regression (ENHANCE) trial, announced in January 2008, demonstrated that ezetimibe use lowered cholesterol levels but did not slow the progression of atherosclerosis.

Objective  To examine the association of this announcement with national patterns of ezetimibe prescribing, including medication initiation and discontinuation, as well as predictors of use.

Design, Setting, and Participants  Retrospective analysis of a national sample of adults 18 years or older who were continuously enrolled in plans of a large US pharmacy benefit manager from 2007 to 2010.

Main Outcomes and Measures  Lipid-lowering therapy prescription claims were categorized as ezetimibe-containing treatments or any other lipid-lowering agent. Initiation was defined as an ezetimibe claim without another in the prior 180 days; discontinuation, as an ezetimibe claim without another in the subsequent 180 days.

Results  From 2007 to 2010, 29.1% of the 10 597 296 continuously eligible adults obtained at least 1 lipid-lowering agent prescription. Among these adults, 17.8% were prescribed ezetimibe and 95.3% another lipid-lowering agent, predominantly statins. Ezetimibe use peaked in January 2008, when 2.5% of all adults were ezetimibe users, but declined to 1.8% by December 2010. The ENHANCE trial announcement was associated with a nonsignificant 0.16% fewer monthly ezetimibe users (P = .11) but a significant 0.14% more monthly monotherapy users and 0.30% fewer users of ezetimibe concomitant with other lipid-lowering agents (both P = .01). The ENHANCE trial was also associated with 0.44% fewer monthly ezetimibe initiations (P = .002) and 10.4% more monthly ezetimibe discontinuations (P < .001), particularly of ezetimibe monotherapy for both. More than half of adults who initiated ezetimibe use did so without first being prescribed another lipid-lowering agent, both before (50%-60%) and after (60%-70%) the trial. Those aged 50 to 64 years and those living in the East South Central US Census division were both more likely to initiate and less likely to discontinue ezetimibe after the ENHANCE trial.

Conclusions and Relevance  After announcement of the results of the ENHANCE trial, nearly 2% of all continuously enrolled adult beneficiaries within a large US pharmacy benefit manager used ezetimibe, although ezetimibe initiations declined and discontinuations increased.

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ezetimibe

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Figure 1.
Time Series of Ezetimibe Use, Initiation, and Discontinuation

Monthly time series, stratified by monotherapy or therapy concomitant with other lipid-lowering therapy, among continuously enrolled adult beneficiaries within a large pharmacy benefit management company in the United States surrounding the January 2008 announcement (vertical line) of results from the ENHANCE trial, 2007 through 2010. A, Overall ezetimibe use; B, ezetimibe therapy initiation; C, ezetimibe therapy discontinuation.

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Figure 2.
Proportion of New Ezetimibe Users Prescribed Any Other Lipid-Lowering Agent

Monthly proportion of new ezetimibe users prescribed any other lipid-lowering agent in the preceding 6 months among continuously enrolled adult beneficiaries within a large pharmacy benefit management company in the United States surrounding the January 2008 announcement (vertical line) of results from the ENHANCE trial, 2007 through 2010.

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