The March 1998 issue of Drug Therapy was devoted to a debate on the management of hypercholesterolemia. Dr. Randall Zusman, responding to the recommendations of the Drug Therapy Committee, authored a thoughtful and well-referenced rebuttal of the Committee’s recommendations for the preferential prescribing of Lescol (fluvastatin) and Lipitor (atorvastatin). Dr. Richard Pasternak, Dr. Tom Lee and Harold DeMonaco provided additional data in support of the Committee’s recommendations. Since publication of the two opposing manuscripts, the HMG CoA reductase inhibitor market has changed dramatically, both locally and nationally, with Lipitor garnering a significant and predominant share. Introduced in 1997, Lipitor ranked third in total sales dollars by the end of 1998, according to Pharmacy Times. (http://www.pharmacytimes.com/top200.html) At the PCHI level, Lipitor prescribing constitutes about 66% of all HMG CoA reductase inhibitor prescriptions for capitated patients enrolled in HMO Blue. (HMO Blue data, Second Quarter 1999) The prescribing habits of physicians in the network are revealing, with considerable variation in choice of HMG CoA reductase inhibitor.

The MGPO prescribing pattern is distinctly different from that of the BWH physicians and of the network as a whole. While Lipitor prescribing predominates for the MGPO physicians, prescribing for Zocor, Pravachol and Mevacor by MGPO physicians is greater than that of the rest of PCHI. The financial impact of these differences in prescribing is significant, both to the prescriber and to the patient. Here are the average prescription costs (data from HMO Blue, Second Quarter 1999):

Here’s the difference in cost incurred depending on choice of drug prescribed, using Lipitor as the standard (based on HMO Blue data Second Quarter 1999):

There is a legitimate debate about the best approach to the management of hypercholesterolemia. Few would argue with the value of cholesterol lowering. While expensive, there is a return on the investment, both financially and clinically. The cost of the therapy varies considerably, however, depending on the HMG CoA reductase inhibitor chosen. The physicians of the MGPO appear to be choosing more costly therapy as compared to the network and, perhaps more importantly, to their colleagues at the Brigham and Women’s Hospital. The question is whether these prescribing differences are due to patient factors, differences in interpretation of the literature or simply marketing. Whatever the cause, the cost of the average prescription for an HMG CoA reductase inhibitor from a physician of the MGPO is considerably more than that of a prescriber elsewhere in the network, including the BWH.

The Drug Therapy Committee continues to strongly recommend the use of fluvastatin (Lescol) and atorvastatin (Lipitor) for patients requiring pharmacologic therapy for LDL-cholesterol reduction.