An expensive anti-cholesterol drug called inclisiran is soon going to be offered through the NHS. It is a twice-a-year injection which contrasts to the well-known cholesterol-lowering drugs, statins, taken as a daily pill by 6.5 million adults in England. Inclisiran also works differently from statins: it lowers cholesterol by using gene-silencing to increase the removal of cholesterol by the liver whereas statins work by reducing cholesterol production in the liver. NICE is recommending inclisiran as an option for those who have already had a stroke or heart attack and are not responding to other cholesterol-lowering treatments for example statins. There is no long-term proof of the benefits of this drug, but it is being recommended based on existing evidence of its benefits. Experts hope that this drug will help prevent further life-threatening cardiovascular events, one of the leading causes of death in the world, in those with high cholesterol levels.
What is cholesterol and why is it bad?
Cholesterol is a lipid found in some foods and also produced in the liver. Although ‘good cholesterol’, also known as HDLs, are beneficial as they remove excess cholesterol from peripheral tissues, reducing the risk of atherosclerosis, ‘bad cholesterol’, also known as LDLs are harmful because they have a long half-life and will thus remain in the blood long enough to be oxidised and can contribute to atherosclerosis. Atherosclerosis is the term used to describe when fatty substances, or plaques, clog the arteries, increasing the risk of heart problems and stroke.
When are statins used and how do they work?
Statins are given when the patient has a 20% increased risk of cardiovascular disease (elderly, diabetic) or have familial hypercholesterolaemia. They work by inhibiting the enzyme HMG CoA Reductase, inhibiting cholesterol synthesis in hepatocytes (liver cells). They also cause a decrease in LDL production, as well as increasing the synthesis of LDL receptors, so that more of it can be taken up rather than being oxidised.
It is usually the first choice of drug and other drugs are only used if adverse effects occur. The adverse effects of statins include hepatic injury and myopathy (muscle pain) These occur when statins are taken in large doses and over a long period of time
- Roleplay question: Your patient has a dangerously high level of cholesterol. Despite suffering a myocardial infarction (heart attack) two months ago, they insist on having a diet high in lipids. They refuse to give up eating a box of pizza every day. ‘It’s my favourite food!’ they yell and begin to get very emotional. How would you advise this patient?
- One of the greatest challenges facing the NHS is funding. Inclisiran is an expensive drug and therefore providing this drug through the NHS is likely to result in substantial costs. Can you give any suggestions for how the NHS could increase funding? Or how would you suggest this drug should be allocated to minimise these costs? Think about the ethical issues surrounding the allocation of resources.
Author: Sana Khan
Editor: Allegra Wisking