Utilisation pattern and expenditures trends of lipid-lowering therapies in Kuwait between 2012 and 2022: a population-based study

Background: Elevated low-density lipoprotein cholesterol (LDL-C) is one of the major risk factors for atherosclerotic cardiovascular disease (ASCVD) in Kuwait. Oral lipid-lowering therapies (LLTs), such as statins, are the cornerstone of therapy to achieve the desired goal of LDL-C; however, Kuwait recently has also approved proprotein convertase subtilisin/kexin type-9 inhibitors (PCSK9Is). These medicines have been shown to positively impact cardiovascular outcomes; however, they are considered expensive. Therefore, it is important to examine the overall utilisation and expenditure trends of LLTs, particularly after the introduction of PCSK9Is, during an 11-year follow-up period.

Methods: This retrospective, repeated cross-sectional study used the electronic system of the Central Medical Store to extract annual aggregated data for the utilisation and costs of LLTs between 2012 and 2022. Oral LLTs of interest included statins (atorvastatin, rosuvastatin, simvastatin, and pitavastatin), cholesterol absorption inhibitor (ezetimibe), and fibrates (fenofibrate, gemfibrozil, bezafibrate). Injectable LLTs included PCSK9Is (evolocumab and alirocumab). The utilisation of LLTs was quantified using number of units supplied/1,000 inhabitants and defined daily doses (DDDs)/1,000 inhabitant/day (TID). The expenditure was measured using costs of units supplied/1,000 inhabitants. The analysis was stratified by governorates, healthcare settings, and statin intensity (atorvastatin 40-80mg and rosuvastatin 20-40mg were considered high-intensity statin therapy (HIST)).

Results: The use of LLTs increased by 52% (n= 71,839) in terms of units supplied/1,000 inhabitants and by 119% (n= 62.2) in terms of DDD/TID, with a rise in expenditure by 136% (n= 30,627). This was mainly driven by the increased utilisation and costs of statins (by 41% (n= 54,501) in terms of units supplied/1,000 inhabitants, by 102% (n= 52.7) in terms of DDD/TID, and by 47% (n= 10,555) in terms of the cost of units supplied/1,000 inhabitants). For PCSK9Is, the utilisation increased by 63- to 77-fold, and the cost increased by 4,195% (n= 14,878).

Conclusion: Over the last decade, there was an expected rapid increase in the utilisation and expenditure trends of LLTs reflecting primarily the recommendations of the current guidelines for the management of dyslipidaemia. Several factors could be associated with increased utilisation and high costs. These included a strict threshold for lipid profile, recommending HIST as first-line therapy for CVD high-risk individuals, newly developed costly yet effective medications with minimal side effects, and preferring dual-/triplet- therapy over monotherapy in certain groups. Therefore, it is imperative to control the pharmaceutical utilisation and expenditure through assessing rational prescribing.