by Seth J. Baum, MD

It’s National Cholesterol Education Month and we have fittingly entered a new era in lipid management. We now know that elevated LDL cholesterol causes heart attacks and strokes. Studies of all types have proved this. The most persuasive proof comes from genetics, specifically Mendelian Randomization studies. Recently our increased genetic knowledge base has enabled us to use such analyses to definitively demonstrate cause and effect. Thus, unequivocally we can today declare that LDL is a key player in causing vascular disease. It’s time therefore to stop referring to the “cholesterol hypothesis” and call it what it is – “the cholesterol epidemic.” This might annoy the cynics among us, but enough is enough. They’ve had their time on the internet soapbox; they’ve already dissuaded too many people from getting the treatment they’ve needed. Indeed, some heart attacks, strokes, and even deaths might have been averted had susceptible people followed the advice of science and medicine instead of popular anti-medicine demagogues. Hopefully such negative voices will soon fall on deaf ears. But it’s not just these naysayers who threaten our patients’ health. Surprisingly it’s also the statisticians/medical economists and insurance providers who evaluate medicine through cold cost-benefit lenses. These policy-makers might be even more menacing than the internet mountebanks.

Just the other day the Institute for Clinical and Economic Review published a report declaring that the novel PCSK9 inhibitors are not cost effective at their current price point. Their carefully calculated Incremental Cost Effectiveness Ratio (ICER) “proved” that to be cost effective these medications would have to be close to $2,000/year, not $14,000. Though some of their assumptions can easily be called into question, my main objection is with the very essence of cost benefit analyses in the realm of medicine. I know we don’t possess infinite resources, but I wonder, “What is a life worth?” How do these ‘experts’ determine the value of a single life? Would they include themselves and their loved ones in the same analysis? If medically indicated for them, would these economists reject a PCSK9 inhibitor because the price tag is simply too high? I doubt it. So how are we physicians to respond to their conclusions, and even worse, to the potential payer-denials driven by their suppositions?

For my part, I believe my duty to be to my patients. Each time I sit with someone to render my opinion I ask myself how I would want to be treated were I in his or her place. This is, I feel, the simplest way for a doctor to offer advice. Regarding the PCSK9 inhibitors, revolutionary medications that can dramatically lower LDL cholesterol under even the most stubborn of circumstances, if I needed one, I would certainly want to get it. As I’ve already alluded, I genuinely think that cost benefit analyses have no role in the patient doctor relationship. In the example in question, I know that high cholesterol kills people. Now that I have access to PCSK9 inhibitors, medications indicated for lowering excessive cholesterol in our highest risk patients – those with familial hypercholesterolemia (FH) or atherosclerotic cardiovascular disease (ASCVD) – I must prescribe them as indicated, sans consideration of price. For anyone to tell me to do otherwise would demand a re-write of the Hippocratic oath. And that I pray will never occur.

For more information on familial hypercholesterolemia (FH), please visit The FH Foundation