Unmet Needs in Cholesterol Management

Peter Salgo, MD: We’ve talked about what patients need. We talked about a very focused attempt to get an individual patient on the correct therapy. Nationwide, what does the country need? What do patients need, as a group, that’s right now not being met?

Jennifer Strohecker, PharmD, BCPS: I think one of the things, which we discussed earlier, was the need to really identify patients who are at risk, earlier, and really address LDL levels before disease occurs and even before the primary prevention phase, so that we don’t have this conundrum of very difficult-to-treat, very difficult-to-manage patients who are very expensive regardless of how we manage them. And I think to address one of the unmet needs would be to be proactive in doing screenings earlier, as part of preventive care, and then focus on early treatment strategies for patients. You say you have a great response with patients with lifestyle modifications for those who will respond and for those who are motivated?

Howard Weintraub, MD: Correct.

Jennifer Strohecker, PharmD, BCPS: We need to become more engaged with patients early in the game, in their earlier years of life, before we have to have tough conversations that are a lot more expensive.

Howard Weintraub, MD: The scenario is, they come into the office and I don’t talk to them about it. They go home and the wife or the husband says, “So, what did the doctor say to you about your weight and your exercise?” We didn’t talk about it. At this point, it becomes unimportant, because if it was important, I would have talked to you about it and that’s not what happened. So, you have got to bring it up, period. And, in doing so, you can engage their degree of interest. If they look at you like they’d rather be boiled in hot oil, then you stop the conversation, but otherwise, you keep going with it.

Gary L. Johnson, MD, MBA: That’s a national tragedy that we have.

Peter Salgo, MD: What is?

Gary L. Johnson, MD, MBA: Twenty or so percent of Americans smoke cigarettes.

Peter Salgo, MD: Is it that high, still? I didn’t know the actual number.

Gary L. Johnson, MD, MBA: I think it’s around 20%. Don’t quote me, but I think it’s in that neighborhood, which, to me, is inexcusable when we talk about cardiovascular mortality. I’m not sure of the relative contributions between lipids and cigarette smoking, but cigarette smoking certainly is a huge factor.

Peter Salgo, MD: We have been talking about these targeting agents to drop your cholesterol and to drop your heart disease risk. We have a problem in America with 20% of people still smoking. What’s the 900-pound gorilla on the table here?

Gary L. Johnson, MD, MBA: Lifestyle.

Peter Salgo, MD: I would think so. So, there is an unmet need. What is the future, now, of cholesterol management? I’m going to broaden this out. What does the future of heart attack risk management look like in this country going forward?

Seth J. Baum, MD: Well, it depends whether we have free reign or not.

Seth J. Baum, MD: Free reign to do what the FDA has already mandated in the prescribing information. The view is very, very optimistic actually. We have the capacity to lower people’s LDL to unprecedented levels. This will reduce heart disease dramatically if we can use these agents, and I think we can make an enormous dent in heart attack, stroke, and death and really change the playing field.

Peter Salgo, MD: It’s not free.

Gary L. Johnson, MD, MBA: Yes, and I don’t disagree with that. Given enough money, we can do just about anything that we want. It’s a societal issue, a financial issue, and a governmental issue of how best to use our resources. And if resources are unlimited, yes, we can do more than what we’re doing now.

Peter Salgo, MD: Have people bought into this? Has the government bought into this, that we can really do this? We can really strike “at the heart” of the heart disease issue? Do you see a buy-in at the federal level?

Jennifer Strohecker, PharmD, BCPS: I would say not yet.

Peter Salgo, MD: How long is it going to take? There were 800,000 deaths last year. That’s a lot of people.

Howard Weintraub, MD: Right, it’s a lot. How I look at it is, with the advent of PCSK9s (proprotein convertase subtilisin/kexin type 9s), there’s a lot less maneuvering to get cholesterol down and you can take this time to focus on obesity and blood pressure and maybe do a little better job with those.

Peter Salgo, MD: So, it takes the pressure off?

Howard Weintraub, MD: Exactly. What this does is it allows you to get at the big 3. When you get a better handle, you can really reduce cardiovascular disease.

Gary L. Johnson, MD, MBA: We touched on this, peripherally before, about earlier prevention and earlier drug therapy. What we haven’t talked about is the use of the PCSK9s in primary prevention. What do you do with the 30-year-old individual who comes into the office, is perfectly healthy, and has an LDL of 130 mg/dL? We know that 30 mg/dL is better than 130 mg/dL long term. You put them on a statin, they agree to take the statin, it comes down to 70 mg/dL, but we know that 30 mg/dL is better than 70 mg/dL. Do we put somebody who’s 30 years old on a very expensive drug for the remainder of their life to reduce that cardiovascular risk?

Peter Salgo, MD: Would you, as a patient, rather be on a statin with its side effect profile for the rest of your life or on one of these newer injectables with a much better side effect profile for the rest of your life?

Gary L. Johnson, MD, MBA: Well, of course.

Howard Weintraub, MD: This is the main issue. I firmly agree with this because the impact of early cardiovascular disease is huge. You can start this out so you get success. Start with the people with family histories. Start with the people who look like Mr. Potato Head, initially, with big bellies and go after them first to see what you can do. If you get some success with early treatment, you generalize it to more of the population. But I agree completely. Statins also have baggage. Google the word statins. I promise you what you come back with is nothing glowing. It comes back with all the horrible stories that they make you stupid, they give you diabetes—all of which is really not necessarily correct. So, I think that these drugs have nothing bad to say except they’re expensive.

Peter Salgo, MD: I’m going to stop for just a moment, because this is a good place. I want to thank all of you for being here. It’s been a tremendous discussion. It’s been wide-ranging and good natured, which is not bad. We have both insurance and practitioners at the same table. But this has been a very interesting discussion on some really promising new agents. You’ve brought some tremendous and interesting detail to this and some texture to this. In the time we have remaining, I want to give each of you one last opportunity to have your last final say. Dr Baum, you’re the first shot.

Seth J. Baum, MD: I guess to conclude this kind of conversation, I would say that since access is such an important aspect of this entire discussion, that the patient needs to get involved. The patient has the loudest voice, and the patient needs to understand this. If the patient is denied a therapeutic that a doctor has prescribed, the patient needs to contact the insurance company; that will have an impact. And I think if I could get that one message across, then that will be valuable.

Peter Salgo, MD: Dr Strohecker?

Jennifer Strohecker, PharmD, BCPS: I think my final statement to our discussion today would be that, what I see in the practice that I am involved in today, patients aren’t really getting their maximal value out of proven medications—statin therapy as well as lifestyle modifications. I think we can all do a better job at helping to get more patients on the right kinds of therapy, and then when we’re able to do this, it’s exciting to think about the other options that are out there that can really help patients have better outcomes.

Peter Salgo, MD: Dr Johnson?

Gary L. Johnson, MD, MBA: My feeling on this is that there’s more common ground than there is adversity, and it’s oftentimes portrayed as an “us against them” type of situation. I don’t really think that’s the case, and I certainly agree that the patient needs to get more involved—both with their responsibilities and obligations to reduce cardiovascular events. I think the future is bright.

Peter Salgo, MD: And Dr Weintraub? You’ve got the last word.

Howard Weintraub, MD: I agree that it should be a partnership between the patient and his physician or her physician. That way there is a better dialogue toward helping them understand what they’re getting treated for. They would then, perhaps, have more of a buy-in. Either lifestyle changes or medicines, they’ll be more likely to adhere to. And then, when it comes time to dig your heels in and put up a good fight to get what they need, they do so with you. And many times, there is a louder voice. As has been said already: when the patient speaks up.

Peter Salgo, MD: I want to thank you all again. Tremendous discussion, wonderful guests. On behalf of our panel, I want to thank you for joining us, and I hope that you found this AJMC Peer Exchange^TM to be informative. I’m Dr Peter Salgo, and I’ll see you next time.