Perceptions and Barriers on the use of PCSK9 inhibitors

Perceptions and barriers relating to proprotein subtilisin/kexin type 9 inhibitors in patients with heterozygous familial hypercholesterolemia.

Key Takeaway

Why This Matters

• Current guidelines recommend add-on PCSK9i therapy for additional LDL-C lowering beyond statins
• Limited information available regarding physicians’ attitudes, practices, and barriers to treatment of HeFH.

Study Design

• Largest US national online survey conducted by NLA included cardiologists (n=500) and PCPs (n=500) for the use of pcsk9i in patients with HeFH, and barriers to its prescription

Inclusion Criteria:

• Licensed physicians, currently practicing, prescribing medications, and reporting caring for patients with a baseline LDL-C ≥190 mg/dL

Exclusion Criteria:

1. Physicians self-identified as lipid specialists*
2. Expected to be knowledgeable about HeFH,
3. Pediatricians,
4. Certified by the American Board of Clinical Lipidology or Accreditation Council for Clinical Lipidology

Key Results

• 1,000 physicians completed the online survey (30-questions)
• Specialty^†: Family medicine, internal medicine, general practitioners
• Practice location^‡: Suburban, urban, rural
• Practice setting^§: Private, health system, academic, Veterans Affairs/government health, system/other
•  
• PCSK9i, followed by ezetimibe, diet and exercise were the most preferred therapies in patients on maximally tolerated statin therapy needing additional LDL-C lowering

Attitudes and Experience with HeFH Treatment (PCPS vs Cardiologists):

• High-intensity statin for HeFH patient with untreated LDL-C ≥190 mg/dL: 64.8% vs 68.6%,(P = 0.04)
• PCSK9i for HeFH patient on maximum statin therapy needing additional LDL-C lowering: 48.4% vs 58.2%, (P <0.01)
• PCSK9i in adult with HeFH on maximum statin therapy, with/without ASCVD: 66.0% vs 87.8%, (P <0.0001) or 51.0% vs 70.2%,(P <0.0001)

Barriers Encountered With PCSKi (PCPs vs Cardiologists):

• Complexity of pre-authorization process: 34.2% vs 24.7%, (P <0.05)
• Time taken for pre-authorization process: 27.8% for both, (P <0.05)
• PCSK9i expensive cost: 12% vs 21.9%, (P <0.01)
• Other barriers: Insurance denials, unwillingness to take injectables, difficulty in documenting a clinical diagnosis of HeFH

PCSK9i Prescription

• Odds of prescribing^¶:
  • PCP vs cardiologists: OR = 0.46, (95% CI = 0.34-0.63)
  • Private vs academic practice providers: OR = 1.53,(95% CI = 1.02-2.28)
• Odds of difficulty in prescribing#:
  • Urban vs rural setting: OR = 0.56, (95% CI = 0.34- 0.93) diagnosis of HeFH

Limitations

• No information on respondents’ demographics such as age, gender, or ethnicity
• Exclusion of lipid specialists with greater knowledge of HeFH
• Results differed if PCP-identified HeFH patient was referred to a lipid specialist
• Bias towards those interested in dyslipidemia

* Including endocrinologists.
^† Family medicine = 46%, internal medicine = 46, general practitioners = 8%
^‡ Suburban = 53%, urban = 37%, rural = 10%
^§ Private = 57%, health system = 24%, academic setting = 17%, Veterans Affairs/government health system/other = 1% each.
^¶ PCSK9i prescribers in a HeFH patient with (OR = 3.86 [2.57-5.78]) or without (OR = 1.96 [1.40-2.72]) ASCVD on maximum statin needing additional LDL-C lowering.
# PCKS9i prescribers in a HeFH patient with (OR = 2.80 [1.74-4.49]) or without (1.43 [1.02-2.02]) ASCVD on maximum statin needing additional LDL-C lowering.

MAT-BH-2200054/v2/Jan 2024