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Tests of Cholesterol Drugs Offer Hope of Reducing Heart Attacks and Strokes

A new class of experimental cholesterol drugs might sharply reduce the risk of heart attacks and strokes, researchers reported on Sunday, citing what they described as preliminary evidence.

The drugs, one being developed by Amgen and the other by Sanofi and Regeneron Pharmaceuticals, are already known to sharply reduce so-called bad cholesterol, sometimes to levels lower than those achieved by statins like Lipitor, the mainstay lipid-lowering medicines.

What has not been known, however, is whether the drugs do what patients and doctors really care about: protect against heart attacks, strokes and other cardiovascular problems or “events.”

The early results suggest that there might be such a benefit, maybe even a big one. In small studies sponsored by the manufacturers, both drugs reduced the rate of such cardiovascular problems by about half.

“To see a reduction in cardiovascular events already is very encouraging that we’re on the right track,” Dr. Jennifer G. Robinson, the lead investigator in the trial of the Sanofi drug, said in an interview.

The studies were published in The New England Journal of Medicine and were being presented at the annual meeting of the American College of Cardiology taking place through Monday in San Diego.

Researchers cautioned, however, that the studies were small and intended to assess whether the drugs lowered the bad cholesterol and were safe, not whether they staved off heart attacks. That could make the conclusions about heart attack and stroke risk less trustworthy. Judging those effects will require larger trials involving tens of thousands of people; such studies are underway and are expected to be completed by 2017.

“I do not think that either study answers the question definitively of cardiovascular benefit,” said Dr. Steven E. Nissen, chairman of cardiovascular medicine at the Cleveland Clinic, referring to the drug makers’ research. He was not involved in either study.

Researchers said long-term safety still must be assessed, especially since these drugs are reducing LDL cholesterol to levels never achieved by medicines before. While the drugs appeared generally safe, there was evidence that they could cause memory problems.

Still, the findings could help smooth the way for regulatory approval, wider use of the drugs by doctors and possibly reimbursement by insurers.

The drugs, evolocumab from Amgen and alirocumab from Sanofi and Regeneron, inhibit a protein in the body called PCSK9 that helps regulate cholesterol. In the studies detailed on Sunday, both drugs reduced the bad cholesterol by about 60 percent, to about 50 milligrams per deciliter from about 120 at the start of the studies. In many cases such big reductions were achieved even though the patients were already taking statins.

Both drugs could win approval from the Food and Drug Administration by this summer. Analysts say the drugs will have billions of dollars in annual sales and will be taken by millions of people who cannot lower their cholesterol enough using statins alone or cannot tolerate statins. (However, the PCSK9 drugs are taken by injection every two weeks or four weeks, which could deter some users.)

Statins reduce cardiovascular risk and scientists believe it is because they decrease low-density lipoprotein, or LDL, the so-called bad cholesterol. But merely looking at cholesterol levels can be misleading. The drug niacin did not protect against heart attacks and strokes even though it raised so-called good cholesterol and modestly lowered bad cholesterol.

Insurers in particular might demand proof that the PCSK9 drugs stave off heart attacks, strokes, deaths from coronary disease and procedures to open arteries before agreeing to pay for them for many patients. Executives at CVS Health, a leading pharmacy benefits manager, recently said that PCSK9 inhibitors might cost $7,000 to $12,000 a year and would strain health care budgets because so many people might use them.

“Managed care pharmacy, indeed the health care system, has never seen a challenge like this to our resilience in absorbing costs,” they wrote in the Health Affairs blog.

Whether the results from these two small studies will be persuasive enough remains to be seen.

The study of Amgen’s evolocumab involved 4,465 patients with various degrees of risk, two-thirds of whom were randomly chosen to get the drug in addition to the medication they were already taking. After one year, 0.95 percent of those in the group that received the drug had suffered a heart attack, stroke or other cardiovascular problem, compared with 2.18 percent in the group that did not take the drug. By a measure known as the hazard ratio, the risk of cardiovascular events was reduced by 53 percent.

The alirocumab study involved 2,341 patients. After one and a half years, the rate of cardiovascular events was 1.7 percent in those who received the drug, versus 3.3 percent in those who received a placebo, a risk reduction of 48 percent.

Dr. Sanjay Kaul, a cardiologist at Cedars-Sinai Medical Center in Los Angeles, said analyses of one measure from trials meant to assess other things were “notorious for not being reliable.” He said the results would not be sufficient to support widespread use of and reimbursement for the drugs.

He noted, for instance, that the alirocumab trial used a narrower definition of cardiovascular events than the evolocumab trial used. Using a broader definition, alirocumab did not provide a statistically significant reduction in cardiovascular problems.

The evolocumab study, for its part, did not use a placebo, so patients and doctors knew who was getting the drug, which could have affected the outcome.

But Dr. Marc S. Sabatine, a cardiologist at Brigham and Women’s Hospital and the lead investigator of the evolocumab study, said the fact that both trials had similar results was reassuring, suggesting the effect was real. The results were also plausible, he said, because people who have genetic mutations that reduce their PCSK9 levels have very low rates of heart attacks.

Dr. Sabatine and Dr. Robinson have been paid consultants to the companies sponsoring the trials they led.

Rating

5 Star

Categories

Tests of Cholesterol Drugs Offer Hope of Reducing Heart Attacks and Strokes

Our Review Summary

This piece did an excellent job addressing all of our criteria and fully merited a 5-star rating. We particularly liked how the independent experts quoted in the story provided a more critical and balanced view of the studies’ findings. Our only significant concern is that benefits are described high up in the story in terms of relative risk reduction, while absolute risks are buried far down in the text of the story. This is an issue we discussed in detail in a blog post about media coverage of these studies.

 

Why This Matters

Lipid-lowering drugs, such as statins, are used to help people lower their cholesterol levels, which doctors believe may reduce the risk for heart attacks and strokes. But some people may not get their cholesterol into the recommended range with statins alone, and others are unable to tolerate a lifelong regimen of statins. If an experimental class of cholesterol drugs is shown to reduce cardiovascular risks and improve patient outcomes, then these may prove to be alternatives or adjuncts to the slew of cholesterol-lowering medications already out on the market. On the other hand, the safety of these new drugs must first be ascertained before they become widely available to consumers.

Criteria

Does the story adequately discuss the costs of the intervention?

Satisfactory

It’s difficult to estimate costs for drugs that haven’t yet been approved by the Food and Drug Administration, so we feel this article did an exceptional job discussing the projected costs of PCSK9 inhibitors. The piece quoted executives at CVS Health who said these drugs may cost $7,000 to $12,000 a year, which may strain health care budgets if many people use them. Furthermore, insurers may be hesitant to pay for PCSK9 inhibitors until there is proof that they prevent heart attacks, strokes and death, it said.

Despite the potential high costs, analysts estimated the drugs will have billions of dollars in annual sales, the article added.

Does the story adequately quantify the benefits of the treatment/test/product/procedure?

Satisfactory

The story did a good job of clarifying the risk of cardiovascular events in each study. For evolocumab, the article said, “After one year, 0.95 percent of those in the group that received the drug had suffered a heart attack, stroke or other cardiovascular problem, compared with 2.18 percent in the group that did not take the drug.” The article went into the same nitty gritty for alirocumab: “After one and a half years, the rate of cardiovascular events was 1.7 percent in those who received the drug, versus 3.3 percent in those who received a placebo.”

We applaud that the piece reported the raw percentages, since it puts the benefits into perspective. But high up in the story, it cites the figures in terms of relative risk reduction, making the benefits sound more impressive: “Both drugs reduced the rate of such cardiovascular problems by about half.”

We encourage stories to report benefits in absolute terms so that readers have a clearer idea of what “risk reduction” really means. And since many readers will not read a long story in its entirety, we encourage journalists to put that information somewhere that readers are likely to see it. If an eye-popping relative risk figure is mentioned high up in the story, it should be accompanied by immediate discussion of what that means in absolute terms.

Does the story adequately explain/quantify the harms of the intervention?

Satisfactory

The article mentioned the drugs could cause memory problems and that long-term safety must still be assessed. The story would have been stronger if it had mentioned the actual rates of memory problems found in the studies. Some mention of the side effects seen with monoclonal antibodies used for other purposes would also have been useful.

Does the story seem to grasp the quality of the evidence?

Satisfactory

The story did a fantastic job cautioning readers on the study’s limitations. The two independent doctors provided much-needed perspectives on the studies’ findings – a contrast from the AP story that quoted an independent expert saying the results were “really impressive.” In The New York Times piece, Dr. Steven E. Nissen said the study did not answer the cardiovascular benefit question definitively. And near its end, Dr. Sanjay Kaul goes specifically into the limitations of each study, such as the alirocumab trial using a narrower definition of cardiovascular events and the evolocumab trial being open label. The story could have done a better job explaining what exactly Dr. Kaul meant by that.

High up in the story, there is immediate notification that the studies were small and preliminary. It also made clear the goals of the studies, which were to assess drugs’ safety and whether they lowered bad cholesterol – “not whether they staved off heart attacks. That could make the conclusions about heart attack and stroke risk less trustworthy,” it said.

These are the statements and perspectives we would love to see more of in health and medical news stories. The New York Times story fully deserves a satisfactory rating here.

Does the story commit disease-mongering?

Satisfactory

The story did not engage in disease mongering.

Does the story use independent sources and identify conflicts of interest?

Satisfactory

The story quoted two independent doctors – Dr. Steven E. Nissen and Dr. Sanjay Kaul – both of whom pointed out the limitations in the studies. The piece also did an excellent job in disclosing potential conflicts of interest, since pharmaceutical companies often finance the development and research of their drugs. The article stated that lead study authors “Dr. Sabatine and Dr. Robinson have been paid consultants to the companies sponsoring the trials they led.” It also made clear the fact early in the story that these studies were “sponsored by manufacturers.”

Does the story compare the new approach with existing alternatives?

Satisfactory

The article briefly compared PCSK9 inhibitors to statins, or other lipid-lowering drugs like Lipitor, stating that this new class of cholesterol drugs reduced bad cholesterol to lower levels than statins. It also mentioned the drug niacin, which did not protect against heart attacks and strokes, despite it raising good cholesterol levels and moderately lowering bad cholesterol.

However, a more thorough discussion on traditional treatments would have been welcome. For example, why are other lipid-lowering medications needed if there are already quite a few out on the market? The AP story addressed this question, explaining many people cannot tolerate statins or get enough help from them.

Does the story establish the availability of the treatment/test/product/procedure?

Satisfactory

The article made it clear that these drugs are in development and not approved by the US Food and Drug Administration, but that such approval could come as early as this summer.

Does the story establish the true novelty of the approach?

Satisfactory

The story states that the new drugs are “already known to sharply reduce so-called bad cholesterol.” It explains that the new studies looked at LDL levels for a longer amount of time and tried to address whether these drugs could protect against heart attacks, strokes and other cardiovascular events.

Does the story appear to rely solely or largely on a news release?

Satisfactory

The article did not seem to be based on this press release or this one. The critical perspectives given by the independent experts in this story are evidence of original reporting.

Total Score: 10 of 10 Satisfactory

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