Current issues of ACP Journal Club are published in Annals of Internal Medicine


Niacin and lovastatin were more efficient than gemfibrozil, probucol, colestipol, or cholestyramine for lowering cardiovascular risk in hypercholesterolemia

ACP J Club. 1991 May-June;114:93. doi:10.7326/ACPJC-1991-114-3-093

Source Citation

Schulman KA, Kinosian B, Jacobson TA, et al. Reducing high blood cholesterol level with drugs. Cost-effectiveness of pharmacologic management. JAMA. 1990; 264:3025-33.



To determine the relative cost-effectiveness of lowering high blood cholesterol with cholestyramine, colestipol, gemfibrozil, lovastatin, niacin, or probucol.


Cost-effectiveness analysis from the perspective of society with effectiveness data obtained from published, randomized, placebo-controlled trials.


Clinical centers in the United States and Europe.


Men and women with type II hyperlipoproteinemia and total cholesterol levels > 6.47 mmol/L.


Patients received monotherapy with cholestyramine, colestipol, niacin, gemfibrozil, lovastatin, or probucol compared with placebo.

Main cost and outcome measures

Improvements in serum lipid levels were used as a proxy for reduction of coronary morbidity and mortality. Pharmacologic effects were assessed as the percentage change in lipid values, estimating the change over 5 years of therapy from long-term trials. Resources consumed with therapy were estimated from a societal perspective, based on treatment protocols developed by an expert panel, and included the direct costs of medications, physician visits, laboratory tests and other monitoring, and adverse effects. Indirect costs were not included. Cost-effectiveness was defined as the present-value cost of therapy over 5 years divided by the percentage reduction of total cholesterol and low-density lipoprotein (LDL)-cholesterol levels, the percentage increase in high-density lipoprotein (HDL)-cholesterol levels, and the percentage increase in an LDL-HDL index. All costs are in U.S. dollars.

Main results

Lovastatin produced the greatest reduction in the LDL-HDL index. Initiation and maintenance costs were lowest for niacin and highest for lovastatin. Annual costs of treatment ranged from $327 to $1881. Using a primary care model, the cost-effectiveness over 5 years was best for niacin (about $112 per percent change in the LDL-HDL index), followed by lovastatin, 20 mg/d (about $165). Cholestyramine was least efficient. The results were sensitive to medication doses and costs and to rates of drug intolerance.


Analyses combining LDL-cholesterol and HDL-cholesterol effects suggest that niacin and lovastatin, 20 mg/d, were more efficient than gemfibrozil, probucol, colestipol, or cholestyramine for lowering cardiovascular risk among patients with type II hyperlipoproteinemia and total cholesterol levels > 6.47 mmol/L.

Source of funding: Merck & Co., Inc.

Address for article reprint: Dr. B. Kinosian, Program in Geriatric Medicine, Ralston-Penn Center, 3615 Chestnut Street, Philadelphia, PA 19104-4283, USA.


The treatment of high blood cholesterol is entering a new phase. As in the treatment of hypertension, several drugs with different modes of action are now available, with more under study, kindling debates about their relative benefits and costs.

The rationale and evidence for appropriate treatment of patients is becoming clearer, with the National Cholesterol Education Program guidelines leading the way. We are learning to decide which patients to treat with drug therapy and why, and we should all by now be familiar with how to use the available drugs. This study looks at drug treatment from a societal perspective by analyzing the cost-effectiveness of lowering cholesterol in an attempt to help the physician include costs in decisions about treatment. To simplify this, the authors used an LDL-HDL index to estimate the reduction in coronary heart disease morbidity and mortality for each cholesterol-lowering agent, based on the findings from the Lipid Research Clinics Primary Prevention Trial, and on the relation of HDL-cholesterol elevation to reduced risk for coronary heart disease, as reported in 4 observational studies. The HDL-LDL index may prove very useful to the clinician. Prescribing trends favoring lovastatin, for example, are supported by the authors' findings, yet why are we not using more niacin? This study points out that drug's high efficacy and low cost.

The study focuses only on intermediate outcomes and omits consideration of interventions to alter or eliminate other cardiovascular risk factors. It is, however, a useful addition to the debate about lowering cholesterol, a debate that will continue as physicians and patients struggle to achieve the best balance between the benefits and costs of drug treatment for hyperlipidemia.

Jerry M. Blaine, MD
Lahey Clinic Medical CenterBurlington, Massachusetts, USA