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Simvastatin targets recommended for review as study shows 'worse cholesterol levels’ in high-prescribing practices

GPs are being advised to switch patients to more potent statins, after an analysis showed practices with higher rates of prescribing had better outcomes in patients and the NHS recommended its simvastatin targets be reviewed.

New research – using data from all general practices in England – has found practices which used a higher proportion of low-cost statins (simvastatin and pravastatin) were less likely to achieve a ‘cholesterol quality indicator’ than those prescribing more atorvastatin and rosuvastatin.

It comes as the NHS Information Centre recommended that the inclusion of low-cost statin prescribing as a QIPP target was put under review.

The body’s December 2012 update on QIPP said it wanted feedback on whether the targets for simvastatin and pravastatin prescribing should be ‘remain unchanged, be retired or amended’, particularly in the light of the reduction in cost due to atorvastatin being available generically.

The indicator was calculated for each practice by taking the number of CHD, stroke and diabetes patients with cholesterol below 5mmol/l and dividing it by the total number of patients on those disease registers.

There was a significant negative correlation between the achievement of the indicator and the use of low-cost statins, with a 10% increase in use of low-cost stains associated with a 0.46% drop in the indicator score.

Study lead Dr Robert Fleetcroft, clinical lecturer in general practice at Norwich Medical School and a GPSI in clinical education, feels that there is a need to re-evaluate atorvastatin in terms of cost-effectiveness, compared to simvastatin.

He said: ‘The performance indicator for low-cost statin prescribing in the NHS Better Care, Better Value indicators, which encouraged the prescribing of low-cost statins, should be re-evaluated.’

He added that with NICE trialling new indicators for diabetes with a stricter 4 mmol/l total cholesterol - with a view to including them in the 2013/14 QOF - hitting cholesterol targets will become harder with the best tolerated dose of simvastatin. This is especially true of patients taking amlodipine or diltiazem after the MHRA warned in August thie best tolerated dose of simvastatin for them is 20mg rather than 40mg.

Dr John Ashcroft, a GP in Derbyshire and member of the Derbyshire CHD committee, believes that greater lowering of LDL cholesterol with more potent statins does not just benefit the patients.

He said: ‘The benefit is probably not just to patients, but to hospitals through lower costs. The work we’ve done in Derbyshire for our CCG shows that for every £1,000 extra spent on atorvastatin 40mg over simvastatin 40mg, on an ‘average patient’, the CCG would expect to deliver a net saving of £650, and a health gain that greater expenditure on secondary care would cost in the order of £7,000.’

He added: ‘Atorvastatin’s current price should save money for the health service and give a substantial health gain for patients to swap. I have started to do this for my patients already.’

BJGP 2012, available online 26 November

Factors influencing cholesterol target achievement

  • Training practices ↑
  • Volume of statin prescribing ↑
  • Low-cost statin prescribing↓

Source BJGP 2012, available online 26 November

Readers' comments (1)

  • More potent statins = more side-effects. Is it really worth it? The absolute risk of a heart attack is reduced by 2% (the total risk is 4%, so a reduction of 50% - the oft-quoted figure - is half of 4%). Any illusory gain in cardiac "health" will in my view be offset by the loss in musculoskeletal health. Let's see.

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