CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

October 31st, 2011

FDA Gives Favorable Review to SHARP Ahead of Vytorin Advisory Panel

In preparation for Wednesday’s meeting of the FDA’s Endocrinologic and Metabolic Drugs Advisory Committee, an FDA reviewer has generally endorsed the positive interpretation of the SHARP trial of Vytorin (ezetimibe and simvastatin) in chronic kidney disease (CKD).

Based on the results of SHARP (Study of Heart and Renal Protection), Merck is seeking an expansion of its indication for Vytorin to include the reduction of major cardiovascular events in patients with CKD. The proposed label from Merck would include a statement noting that any added benefit for the combination of ezetimibe and simvastatin over simvastatin alone “has not been definitively established.”

Currently there are no drugs specifically available to CKD patients that reduce the high risk of CV events in CKD, although statins sometimes have been used. Previous studies have shown that statins are not beneficial in patients with end-stage renal disease, but the potential benefits in patients at earlier stages in the disease – including two thirds of patients in SHARP –  had not been tested until now.

SHARP was the subject of discussion and controversy when it was first presented last November.

The analysis of SHARP by the FDA reviewer found that the combination of ezetimibe and simvastatin reduced the rate of major vascular events by 16% (p=0.001) compared with placebo. This result appeared robust, holding up to a number of different secondary and exploratory analyses.

The beneficial effect was much larger in the subgroup of 6,247 patients who were not on dialysis at the time of randomization (22% risk reduction) than in the subgroup of  3,023 patients on dialysis at randomization (6% risk reduction). The test for heterogeneity did not find a significant difference in treatment effect based on dialysis status, however (p=0.08).

The reviewer raised no red flags about safety. Cancer, which had been a subject of intense concern in the past, was not an issue. The rate of incident cancer was 9.4% with ezetimibe-simvastatin group versus 9.5% with placebo, although there were 18 more cancer deaths in the intervention group than in the placebo group (132 [2.8%] versus 114 [2.5%]).

Categories: Prevention
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3 Responses to “FDA Gives Favorable Review to SHARP Ahead of Vytorin Advisory Panel”

  1. George Shaw, M.D. says:
    November 1, 2011 at 7:32 am

    Clearly a ploy to get us all using this combination, despite there being no evidence that it is better than statin alone.

  2. Robert Hennessy, MD says:
    November 2, 2011 at 8:41 am

    Agree with Dr Shaw

    Competing interests pertaining specifically to this post, comment, or both:
    none

  3. Mikael Rabaeus, MD- FAACVPR says:
    November 4, 2011 at 4:06 am

    I agree. I would go further: analysis of the detailed results show that the decrease in “atherosclerotic events” (which is the terminology chosen by the authors, not vascular) is very largely driven by a decrease in revascularisation. Mortality, in particular, is strictly identical.
    Revascularisation is NOT a clinical event, it is a medical decision and is thus highly susceptible to be flawed, most of the time certainly unintentionally.
    To me, SHARP confirms the previous studies of lipid-lowering treatments in CKD, i.e. NO significant effects.
    I am not going to change my non-prescription habits of Vytorin after this decision.

    Competing interests pertaining specifically to this post, comment, or both:
    Strictly none