LDL-C target attainment and treatment costs in high-risk and very-high-risk patients with or without bempedoic acid: A Spanish cohort simulation

Achieving low-density lipoprotein cholesterol (LDL-C) targets remains challenging for Spanish patients at high (HR) or very-high (VHR) cardiovascular risk, despite treatment with statins and/or ezetimibe (EZE). Escalation to PCSK9 inhibitors (PCSK9i) or inclisiran (INC) is limited due to budgetary concerns. This study evaluates the impact of incorporating bempedoic acid (BA) into lipid-lowering treatment algorithms on LDL-C target attainment and treatment costs. A Monte Carlo simulation used real-world data from 34,967 Spanish adults with HR (29%) or VHR (71%) and uncontrolled LDL-C despite ≥4 weeks of statin treatment with or without EZE. Four treatment sequences were assessed, comparing strategies with and without BA prior to escalating to PCSK9i or INC. In cases where BA did not achieve control, the treatment was switched to PCSK9i/INC, with the BA effect reversed. After simulating the effect of EZE treatment, 17% of patients achieved LDL-C targets. Adding BA enabled an additional 32% of patients to achieve control. Subsequent escalation to injectables further improved control (+49% PCSK9i; + 39% INC). Direct escalation to PCSK9i/INC achieved the same overall control levels (98% PCSK9i, 88% INC) but at higher costs. Incorporating BA before injectables reduced annual treatment costs by almost 30% (-29.8% PCSK9i; -27.2% INC). Introducing BA prior to injectable therapies offers a clinically effective strategy for LDL-C management in HR and VHR patients, significantly reducing budget impact while maintaining high control rates.