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Experts urge GPs to challenge statin prescribing guidance

Experts have encouraged prescribers to overloook risk threshold guidance in statin prescribing and instead leave the choice up to the patient.

Writing in an editorial in Prescribing, researchers including UK cardiologist Dr Aseem Malhotra argued that using risk thresholds to determine statin prescribing to patients at risk of developing cardiovascular disease represents a failure to take into account patient preference.

They suggested instead a process of explaining the scientific evidence on benefits and risks of taking statins, benefits of a healthy diet, taking exercise and quitting smoking, and then asking the patient to decide for themselves.

The experts said: ‘What current guidelines… fail to address is the negative value assignments associated with commonly prescribed and recommended healthcare interventions. Hopefully most clinicians and patients will agree with the principle that information is power.

‘While not all patients will want to take the pills, undergo invasive procedures, or take on lifestyle changes commonly used for risk factor modification, all should have access to basic facts and evidence about the utility of these options.’

NICE recommends that patients are offered statin treatment if they have over a 10% risk of developing cardiovascular disease but has withdrawn its suggestion to add a QOF incentive at this threshold following heavy critique from GP leaders.

Last week, NICE published a new quality standard recommending doctors to take a range of measures before prescribing a statin at a 10% risk threshold.

The quality standard said healthcare professionals caring for people in danger of developing CVD, or who already have CVD, should:

  • offer over-85s identified with an estimated increased risk of CVD a full formal risk assessment using the QRISK2 tool;
  • give adults with a 10-year risk of CVD exceeding 10% advice on lifestyle changes before any offer of drug intervention;
  • assess adults with a 10-year risk of CVD exceeding 10% for secondary causes of hyperlipidaemia before any offer of statin therapy;
  • and have a discussion of the risks and benefits of startin statin therapy with adults at a 10-year risk of CVD exceeding 10% for whom lifestyle changes are ineffective or inappropriate.

It comes as US researchers called for caution on statin prescribing in very elderly, after finding 34% of US over-80s are now on statins, compared to 9% in 1999.

Writing in a letter to JAMA Internal Medicine, Ohio State University researchers led by Dr Michael Johansen urged prescribers to be more cautious because of the ‘potential dangers of expanding marginally effective treatments to untested populations’.

Readers' comments (4)

  • Vinci Ho

    Ha ha ha
    Shouldn't this be the case in the very first beginning?
    This is exactly between working up the science and treating people as a person . We have been doing the latter every day . But has NICE learnt the lesson? Not so sure.......:

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  • I was reading the article and thinking exactly the same as VH

    They suggested explaining the benefits and risks; then the alternative options and how good/ bad they are relative to the drug then letting the patient decide.

    I remember them telling me something about that in medical school. It was called consent. I am pretty sure that it should not be limited to statins.

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  • "They suggested instead a process of explaining the scientific evidence on benefits and risks of taking statins, benefits of a healthy diet, taking exercise and quitting smoking, and then asking the patient to decide for themselves."

    And cardiologists and their specialist nurses are ideally placed to provide this service !

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  • Maybe we should start do this for hypertension.

    We tell patients they have "hypertension", like its some disease, which it isnt. And then prescribe them far more dangerous treatments, that give less benefit than statins, and often to patients with far lower risk. And this is even when patients have far more chance of altering the risk factor than they do with cholestrol.
    (2/3 of hypertension now secondary to obesity)

    The way forward is Calcium Scoring.

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