ENHANCE Results Yield Disappointment for Ezetimibe

ENHANCE Results Yield Disappointment for Ezetimibe

from Heartwire — a professional news service of WebMD

Sue Hughes


January 14, 2008 (Whitehouse Station/Kenilworth NJ) – The results of the long-awaited and controversial ENHANCE trial, finally announced today, have shown no benefit of the combination of ezetimibe (Zetia, Merck/Schering-Plough Pharmaceuticals) and simvastatin (sold together as Vytorin, Merck/Schering-Plough Pharmaceuticals) over simvastatin alone.

The trial, which has been dogged with controversy in recent months, was conducted in 720 patients with heterozygous familial hypercholesterolemia and showed no significant difference in the primary end point–mean change in the intima media thickness (IMT) measured at three sites in the carotid arteries–between patients treated with ezetimibe/simvastatin 10/80 mg vs patients treated with simvastatin 80 mg alone over a two-year period.

ENHANCE: Primary end point

End point

Ezetimibe plus simvastatin

Simvastatin alone


Change in mean carotid IMT after 2-y treatment (mm)




At baseline, the mean carotid IMT measurement for the ezetimibe/simvastatin group was 0.68 mm and for the simvastatin-80-mg group was 0.69 mm. There was also no statistically significant difference between the treatment groups for each of the components of the primary end point, including the common carotid artery. Key secondary imaging end points showed no statistical difference between treatment groups.

Huge disappointment

These results will be a huge disappointment to Merck and Schering-Plough. Ezetimibe, which has a complementary action to the statins, preventing the intestinal absorption of cholesterol and generally adding an extra 20% LDL reduction to that seen with statins alone, is a relative newcomer to the cholesterol market but is already generating blockbuster sales, said to be in the region of $5 billion. That is despite the fact there have been no outcome data available on the drug.

The ENHANCE trial is the first major study to be conducted with ezetimibe, which is why the results were so eagerly anticipated. Although it is not a clinical-outcome study, carotid ultrasound studies monitoring the effects of drug therapy on atherosclerotic plaque are seen as reliable surrogates and normally predict whether a drug will be effective in lowering cardiac events. The results were originally expected to be reported about a year ago, and this had led to much speculation in recent months that they were being delayed as they were negative, although this was denied by the companies and the lead investigator.

More details

Further results from the ENHANCE trial show that the overall incidence rates of treatment-related adverse events, serious adverse events, or adverse events leading to discontinuation were generally similar between treatment groups. There were no cases of rhabdomyolysis. Both medicines were generally well tolerated.

ENHANCE: Adverse events

Adverse events

Ezetimibe plus simvastatin, n (%)

Simvastatin alone, n (%)

Consecutive elevations of serum transaminases (>3 times the upper limit of normal)

10/356 (2.8)

8/360 (2.2)

Elevated creatine phosphokinase (>10 times the upper limit of normal)

4/356 (1.1)

8/360 (2.2)

Creatine phosphokinase >10 times the upper limit of normal associated with muscle symptoms

2/356 (0.6)

1/360 (0.3)

As expected, ezetimibe was associated with a larger reduction in LDL cholesterol.

ENHANCE: LDL values at baseline and % reduction after treatment


Ezetimibe plus simvastatin

Simvastatin alone


Baseline LDL (mg/dL)




Reduction after 2-y treatment (%)




Cardiovascular events similar

And there were no differences in cardiovascular events between the two groups in the trial, which was not powered to assess cardiovascular clinical-event outcomes.

ENHANCE: CV events


Ezetimibe plus simvastatin, n

Simvastatin alone, n

CV death



Nonfatal MI



Nonfatal stroke






There were no noncardiovascular deaths or incidents of resuscitated cardiac arrests in the ENHANCE trial.

Larger outcome trials under way

Merck/Schering-Plough are stressing that this was a surrogate-end-point trial, and they are currently conducting three large outcomes trials with ezetimibe/simvastatin that involve more than 20 000 high-risk patients, including the more-than-10 000-patient IMPROVE-IT trial. No incremental benefit of ezetimibe/simvastatin on cardiovascular morbidity and mortality over and above that demonstrated for simvastatin has been established, they note.

The ENHANCE trial used digitized single-frame ultrasound technology for imaging purposes. There were 357 patients randomized to ezetimibe/simvastatin and 363 to simvastatin. The study collected more than 30 000 carotid artery and 10 000 femoral artery images from these patients. Single-frame ultrasound images were analyzed from the right and left carotid arteries at three sites (the common carotid, the internal carotid, and the carotid bulb) and at numerous time points (baseline and six, 12, 18, and 24 months). Images from the right and left common femoral arteries were analyzed at these same time points as well.

The complete contents of Heartwire, a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.

Related Links

Resource Centers

Cardiometabolic Risk Factor Management (Metabolic Syndrome) Resource Center
Risk Factor Management

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s