Thread by @VietHeartPA

#CVLipids #CardioTwitter #PriorAuthDenial

A thread for education, dissipation of annoyance, and showcase for silliness of insurance prior authorization. @UHC @askUHC @UHC_EH @myUHC 1/

#PCSK9i
1.Proprotein convertase subtilisin/kexin type 9 (PCSK9) binds to LDL Receptor (LDLR)
2.LDLR, protein that brings LDL into the liver cell to be broken down
3.PCSK9=overmanaging boss who fires you despite a job well done
#CVLipids #CardioTwitter #PriorAuthDenial 2/

Source of graphic above: pharmaceutical-journal.com/article/featur… Excellent read by the way :) #CVLipids #CardioTwitter #PriorAuthDenial 3/

Explain #PCSK9i to pt:
Mutations of PCSK9 (the boss):
-gain of fxn –MBA program taught to fire good workers to save on salary cost
-loss of fxn – MBA program taught hands-off approach, allowing great employees to do great work
#CVLipids #CardioTwitter #PriorAuthDenial 4/

I explain to pts, LDLR is the waste engineer, picks up waste (LDL), bringing it into the cell to be degraded. PCSK9 is the boss who rides along, sees great work being done, and promptly fires the LDLR. ncbi.nlm.nih.gov/pmc/articles/P…
#CVLipids #CardioTwitter #PriorAuthDenial 5/

PCSK9i: Alirocumab, Evolocumab – Human monoclonal antibodies.
1)Bind to PCSK9 so it does not interfere with LDLR
2)LDLR brings LDL into the cell to be degraded
3)LDLR survives to come back to cell surface to remove more LDL
#CVLipids #CardioTwitter #PriorAuthDenial 6/

PCSK9i is effective. >50% further reduction of LDL-C as add on to max tolerated statin +/- ezetimibe
#CVLipids #CardioTwitter #PriorAuthDenial 7/

What were the populations for Odyssey Outcomes and Fourier?
#CVLipids #CardioTwitter #PriorAuthDenial 8/

Lowering LDL-C is fine. That’s what the guidelines suggest. But does it lead to further CV risk reduction? RRR was 15% in the primary endpoint.
#CVLipids #CardioTwitter #PriorAuthDenial 9/

FDA approval and indications:
Both Alirocumab (75 or 150 mg/mL q2/wk, or 300 mg/mL q4/wk) and Evolocumab (140 mg/mL q2 wk, or 400 mg/mL q4/wk injections), FDA approved in 2015.
#CVLipids #CardioTwitter #PriorAuthDenial 10/

PCSK9i Summary
#CVLipids #CardioTwitter #PriorAuthDenial 11/

<40 yo pt w/ recent NSTEMI, LDL >400 mg/dL at presentation. LDL-C >140 mg/dL on max rosuva + eze. Based on PCSK9i FDA indications above, does this patient meet criteria for PCSK9i? #CVLipids #CardioTwitter #PriorAuthDenial 12/

How much more important for PCSK9i if above patient evaluated and found to have HeFH (they were and do)? Does this check enough boxes for you @UHC @askUHC @UHC_EH @myUHC? 13/13

Please read and answer above #CVLipids #CardioTwitter #PriorAuthDenial @DLBHATTMD @nationallipid @JPSwcpmc @DaveDixonPharmD @LipidDNP24 @JSaseenPharmD @MichaelJBlaha @BudoffMd @mmillermd1 @DrMichaelShapir @khurramn1 @ErinMichos @hvanspall @AL_Catapano @kcferdmd @alanbrownmd

For those who prescribe pcsk9i, how often do colleagues ask if you adjust when “LDL-C is too low”. #cvlipids #cardiotwitter

What is too low to you? (mg/dL) #cvlipids #cardiotwitter

Fourier trial thelancet.com/pdfs/journals/… #cvlipids #cardiotwitter

Fourier/Ebbinghaus - cognition in those with achieved LDL-C of <20 mg/dL sciencedirect.com/science/articl… #cvlipids #CardioTwitter