We appreciate the authors’ comments contained in their letter, which enabled the correction of an error in the cost of evolocumab at 10 years reported in the article previously published online (the correct average costs of evolocumab and standard treatment are 47 297.16 and 1622.63 euros respectively). We will now elaborate on some of the comments made on the study.1 First, we believe that to facilitate understanding it is important to consider the results of the key variables in absolute values. Thus, while it remains true that there is a relative reduction of 15% and 20% in the primary and secondary variables, respectively, this difference can be expressed as a 1.5% reduction in both variables compared with the total population. For every 100 patients treated, there were 1.5 fewer patients with an event in the intervention group than in the control group.

We agree that it is difficult to collect data on cost, and hope that the IMPACT-HTA project, whose aims include the creation of a repository of direct and indirect costs, will facilitate future economic assessments.2

Ideally, we would have access to information on evolocumab treatment outcomes in a population with the same conditions of use established in Spain (≥ 100mg/dL), but, as mentioned in the discussion, the efficacy was not superior in patients with higher levels of low-density lipoprotein cholesterol. It would also be interesting to use a time scale longer than 10 years, but only 26 months of evidence was available. Projecting the effects over time does not improve the evidence, as costs increase simultaneously. No benefit was reached in cardiovascular mortality (hazard ratio=1.05; P=.62); to explain this finding, it would also be pertinent to know the cardiovascular variables not described.

Finally, the lack of an effectiveness threshold makes it difficult–although not impossible–to draw conclusions, which are obviously open to debate.3 To conclude that evolocumab is not cost-effective for the Spanish National Health System would be in line with the findings that it has not been demonstrated to be cost-effective in other counties such as the United Kingdom, Austria, and Finland, as well as the United States.4