Accessibility to LDL-C Lowering Treatments
Access to medication in LMICs is limited (67). If LDL-C lowering
treatments are not included in the basic medication plans, the
population requiring treatment will not have access due to financial
barriers. The availability of medication for chronic diseases (including
ASCVD) was reported to be less than 30% in public facilities across six
LMICs, with a wide variation in affordability of one month of IHD
treatment, ranging from 1.5 to 18.4 days of a minimum wage (68).
Affordability of combination therapy for secondary prevention of ASCVD
(aspirin, beta-blockers, ACE inhibitors, and statin) using a threshold
of 20% of per household capacity to pay was evaluated. In low income
countries, the use of the four drugs was not affordable for 60% of
participants, and 33% of those in lower-middle income countries (68).
Access to pharmacological treatment for LDL-C is uneven within the
countries in the region. Costs of these treatments may be more relevant
in some instances. For example, in Brazil, the median cost of the
recommended statin for ASCVD was only affordable for 3% of Brazilian
households (67, 69). High-intensity statins are available in various
public health systems across the region. However, in some countries
these medications are not covered, making them unaffordable for the
majority of the population (70). In other scenarios, high intensity
statins, although approved, are not available at local pharmacies. The
alternative to access medication through judicialization is a reality in
several LATAM countries; this strategy demonstrates the need to
implement effective measures for the correct access to medication (71).
Decreasing drug prices achieved with the introduction of generics have a
strong impact on the incremental cost-effectiveness ratio for statin
therapy and may prove to be appropriate treatment even for very low-risk
patients. From a cost perspective, treatment decisions should not be
made strictly based on financial criteria, but through an evaluation of
each patient’s risk level as well as the current drug availability. It
should be noted that treating patients based purely on an evaluation of
cost-effectiveness would mean statin therapy should be expanded beyond
current treatment guidelines to include lower risk patients (72). The
programs that follow the clinical practice guidelines based on statin
reduction of LDL-C are cost-effective across the spectrum of
cardiovascular risk. The addition of ezetimibe and PCSK9i for high risk
patients and patients with high-risk FH is also cost effective. These
economic analyses are needed to allow health systems to recognize the
population that will benefit from such therapies (73).
Several access barriers to management of ASCVD have been identified
across the region. Medical inertia to implement preventive medicine has
been reported in LATAM countries (74) because physicians treat the
disease and not the cardiovascular risk.
Some of the programs implemented in LATAM are aimed at reducing NCDs and
focus on reducing ASCVD, however, LDL-C profiles are not measured and
treatment awareness in both the primary and secondary settings is
lacking (74). Throughout the years, LATAM has strengthened the generic
medication policy by encouraging uptake in treatment by patients, aiming
to reduce the number of deaths and hospitalizations due to NCDs (75-77).
ASCVD is the leading cause of death in LATAM and despite a consistent
decrease in mortality trends it continues to account for over 5 years of
life lost in most countries (78).