National Drug Formulary review of statin therapeutic group using the multiattribute scoring tool

Figures & data

Table 1 Weights assigned to the selection criteria by members of the working committee

Attributes	Selection criteria (factors)	AR	HH	NS	FAMY	RL	HC	LMT	Average weight
Efficacy	Clinical efficacy	16	10	20	22	13	13	17	15.9
	Medium/long term effects	19	10	20	15	17	18	18	16.7
		Weight subtotal (efficacy)							32.6
Safety	Drug interactions	12	5	10	5	10	8	10	8.6
	Serious side effects	10	10	10	10	10	10	10	10.0
	Documentations	8	5	10	10	5	10	5	7.6
		Weight subtotal (safety)							26.2
Drug applicability	Formulations and drug strength	0	10	2	5	5	6	2	4.3
	No of approved indications	7	5	5	5	5	5	7	5.6
	Dose frequency	2	0	2	0	3	3	2	1.7
	Frequent (but not serious) side effects	6	5	3	8	4	4	5	5.0
	Interaction with food	5	5	1	5	2	3	2	3.3
	Dose adjustments	5	5	2	5	6	5	2	4.3
		Weight subtotal (patient acceptability)							24.2
Economics	Costs	10	30	15	10	20	15	20	17.1
	Total	100	100	100	100	100	100	100	100

Note: Figures in bold are weight subtotal for each attribute, for example 32.6 is the weight subtotal for efficacy.

Abbreviations: AR, Azuana Ramli; HH, Hariana Haris; NS, Noraini Saari; FAMY, Faridah Aryani Md Yusof; RL, Rosliza Lajis; HC, Haarathi Chandriah; LMT, Lim Ming Tsuey.

Table 2 Table of the clinical efficacy scores of statins

Drug	Drug dose in chosen trial (mg/day)	Mean reduction in LDL-C in trials (%)	Defined daily dose	% LDL-C reduction (to input in scoring)	Strength of evidence score	Calculated utility score (efficacy)	% of patients obtained LDL-C goal^Citation22,Citation23,*
Pravastatin^Citation23	10–40 mg	20–29	30 mg	27	1	58.0	31–55
Simvastatin^Citation23	10–40 mg	28–39	30 mg	37	1	72.9	51–66
Lovastatin^Citation25	40 mg	30	45 mg	31	1	64.0	NA
Atorvastatin^Citation23	10–80 mg	37–51	20 mg	42	1	80.4	69–82
Rosuvastatin^Citation23	10–40 mg	46–55	10 mg	46	1	86.3	82–89
Fluvastatin^Citation25	40 mg	24	60 mg	27	1	58.0	NA

Notes:

* This information is tabled to confirm the relative efficacies of the statins compared.

Abbreviations: LDL-C, low-density lipoprotein cholesterol; NA, not available.

Table 3 Medium/long-term effect (clinical endpoints) scores

Drug	Trial reference N: studied/control	Population studied	Reported ARR of CVE (%)	# R/S for 1° prophylaxis of CVE	# R/S for 2° prophylaxis of CVE	Calculated utility score
Pravastatin	MEGA 2006^Citation39 N: 3,866/3,966	Hypercholesterolemic and no history of CHD or stroke	1.10	Adult IIA/category A	IIA/B	79.17
	PROSPER 2002^Citation40 N: 2,891/2,913	Age 70–82 years; either pre-existing or raised risk vascular disease: TC of 4.0–9.0 mmol/L	2.25
Simvastatin	HPS 2002^Citation41 N: 10,269/10,267	Age 40–80 years with CHD, other occlusive arterial disease or DM	3.06	Adult IIA/category A	IIA/A	84.85
Lovastatin	AFCAPS/TEXCAPS 1998^Citation42 N: 3,304/3,301	Without clinically evident atherosclerotic CVD with average TC and LDL-C levels	1.58	Adult IIA/category A	IIA/B	79.17
Atorvastatin	SPARCL 2006^Citation43 N: 2,365/2,366	Had had a stroke or TIA within one to six months before study entry, LDL-C levels of 2.6 to 4.9 mmol/L, and had no known CHD	3.1	Adult IIB/category B	I/A	84.85
	CARDS 2004^Citation44 N: 1,429/1,412	With type 2 DM without elevated LDL-C and at least one of retinopathy, albuminuria, current smoking, or hypertension	3.2
Rosuvastatin	CORONA 2007^Citation45 N: 2,514/2,497	At least 60 years of age with NYHA class II, III, or IV ischemic, systolic heart failure	1.8	Adult IIB/category A	IIB/B	60.23
	JUPITER 2008^Citation46 N: 8,901/8,901	Healthy individuals with low LDL-C levels but elevated C-reactive protein	0.83
Fluvastatin	HYRIM^Citation47 N: 283/285	Drug-treated hypertensive men age 40–74 years with Total-C 4.5–8.0 mmol/L, BMI 25–35 kg/m^2, and a sedentary lifestyle	1.38	Adult IIB/category B	IIA/B	67.80

Notes: The trial list is not exhaustive. Results of trials are mainly accessed through Trials-Results Centre website at http://www.trialresultscenter.org/. ^#Information Source, Micromedex.

Abbreviations: ARR, absolute risk reduction; CVD, cardiovascular disease; CVE, cardiovascular events; R/S, recommendation and strength of evidence; TC, total cholesterol; LDL, low density lipoprotein; CHD, coronary heart disease; TIA, transient ischemic attack; NYHA, New York Heart Association functional classification for heart failure.

Table 4 Weighted utility scores and total utility scores

Assigned weight	15.9	16.7	8.60	10.0	7.60	4.30	5.50	1.70	5.00	3.30	4.30	17.1
Factors	Efficacy	Medium/long-term effect	Drug interaction	Serious SE	Documentation	Formulations	Indications	Dose frequency	Frequent SE	Interaction with food	Dose adjustments	Cost	TUS without cost	TUS (all)
Pravastatin	9.23	13.22	7.15	9.03	6.84	3.87	4.40	1.70	4.41	3.30	3.01	15.97	66.15	82.13
Simvastatin	11.59	14.17	4.60	7.76	7.60	3.87	5.50	1.70	3.64	2.31	3.01	16.70	66.40	83.11
Lovastatin	10.17	13.22	5.09	9.–03	6.08	3.87	4.40	1.70	4.80	2.31	3.01	17.09	64.34	81.43
Atorvastatin	12.78	14.17	6.72	6.19	6.84	3.87	5.50	1.70	3.39	3.30	3.44	16.58	67.89	84.48
Rosuvastatin	13.72	10.06	7.54	9.46	6.08	3.87	5.50	1.70	3.05	3.30	3.01	12.33	67.30	79.63
Fluvastatin	9.23	11.32	7.29	9.03	6.08	4.30	4.40	1.70	3.93	3.30	3.01	7.26	63.60	70.86

Abbreviations: TUS, total utility score; SE, side effects.

Table 5 Sensitivity analysis: varying assigned weights

Assigned weights (%)
Efficacy	25	40	20
Safety	25	20	20
Patient acceptability	25	20	20
Costs	25	20	40
Total utility score (ranking)
Atorvastatin	86.51 (1)	85.71 (1)	88.51 (1)
Simvastatin	85.23 (2)	83.92 (2)	87.57 (2)
Pravastatin	84.50 (3)	81.31 (4)	86.28 (4)
Lovastatin	83.96 (4)	81.47 (3)	87.15 (3)
Rosuvastatin	79.94 (5)	78.62 (5)	78.27 (5)
Fluvastatin	69.67 (6)	68.32 (6)	64.19 (6)

Table S1 Clinical trials included in the analysis

No	Attributes	Attribute weight (%)	Factor no	Factors/selection criteria	Factor weight (%)
1	Efficacy/effectiveness	*	1a	Clinical efficacy	#
			1b	Effect on clinical endpoints	#
2	Safety	*	2a	Drug interactions	#
			2b	Rare, hazardous side effects	#
			2c	Documentation	#
3	Drug applicability	*	3a	Number of formulations available	#
			3b	Number of approved indications	#
			3c	Dosage frequency	#
			3d	Frequent side effects	#
			3e	Interaction with food	#
			3f	Dose adjustments in special population	#
4	Economics	*	4a	Costs	#
	Total	100%			100%

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