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A faulty production line

Two-thirds of GPs disregard NICE advice to offer statins to more patients

Exclusive The majority of GPs are not complying with NICE advice that they should prescribe statins to more low-risk patients, a Pulse survey has revealed.

Two-thirds of GPs said they have not begun prescribing statins to patients who are newly eligible for the drugs since NICE lowered the risk threshold for primary prevention from a 10-year risk of 20% to 10%, in updated lipid guidance released over the summer.

The chair of the GPC prescribing committee told Pulse there should be ‘no.. slavish devotion’ to guidelines, while GPs indicated they have ongoing doubts there is enough evidence that the benefits of statins outweigh the harms in lower-risk people, and concerns around the increased workload and ‘medicalisation’ of healthy people.

NICE pushed through the lower 10% threshold when it published revised lipid modification guidelines in July this year, despite strong objections from the GPC on the grounds it was not evidence-based and could lead to increased consultations and medicalisation of healthy people to the cost of more needy, unwell patients.

Pulse’s survey of more than 560 GP respondents reveals that so far two-thirds – 66% – said they had not begun prescribing statins at the 10% risk threshold.

Dr May Cahill, a GP partner in Hackney, east London, said: ‘I am not convinced they will do any good, the side-effects are horrific. Why give something to a patient that you would not take yourself nor recommend a family member or friend to?’

Among the 30% of respondents who said they have now started to prescribe statins to people at the new risk threshold, some indicated support for NICE’s position but others also said they were concerned not to stray from the guidance, despite having reservations about it.

For example, Dr Dominic Wood, a GP partner in Beaconsfield, Buckinghamshire, said: ‘[We are] advised to by NICE, don’t want to be left open for medico-legal negligence. Fear of complaints.’

The chair of NICE, Professor David Haslam, recently claimed the intention of the NICE lipid guidance was ‘never to put millions more patients on statins’, and pledged NICE advisors would in future request all trials data from pharmaceutical companies.

Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee, said: ‘The important thing is that GPs continue to do what is in the best interests of their patients, using the NICE guidance as one of the sources of information they draw on to do this.

‘There has never been any dispute that some patients in the 10-20% range will be treated, and indeed some with a higher risk won’t – what is clear is that there should be no automatic prescribing based on slavish devotion to a simplistic mathematical model of risk.’

A NICE spokesman said: ‘Anyone, regardless of cholesterol level, can have their CVD risk reduced by statins. The issue is at what level that becomes cost-effective and sensible practice. Our view is that that level is at a 10% ten-year risk.

‘We acknowledge that clinical guidelines are not mandatory but they are authoritative, based on the best available evidence and we expect the NHS (including GPs) to take them into account whenever patients are being advised on disease prevention or management.

‘We are of course concerned that our guidance should carry the support of the professions. This survey should not be ignored but, given the small number of responses, nor should it be considered to represent the informed opinion of the GP community as a whole. Cardiovascular disease maims and kills people; our guidance will prevent many lives being destroyed.’

Survey results

Question: Have you begun prescribing statins to patients with a 10-year CV risk of 10% or higher?

Yes - 174 (31%)

No - 374 (66%)

Don’t know - 16 (3%)

About the survey: Pulse launched this survey of readers on 10 October 2014, collating responses using the SurveyMonkey tool. The 24 questions asked covered a wide range of GP topics, to avoid selection bias on any one issue. The survey was advertised to readers via our website and email newsletters, with a prize draw for a Samsung HD TV as an incentive to complete the survey. As part of the survey, respondents were asked to specify their job title. A small number of non-GPs were screened out to analyse the results for this question. This question was answered by 564 GPs.

Related images

  • mixed statins assortment packaging  PPL

Readers' comments (15)

  • Have two thirds of GPs actually read the NICE guidance? (or just the headlines from the media?). NICE state that patients should be 'offered' a statin - to allow a discussion of the risks and benefits to take place and enable the patient to make an informed decision. It also emphasises that lifestyle issues should be addressed initially, with a recalculation of the CV risk and only then if the risk is greater than 10% should a statin be offered. Some people will get side effects with statins, but the majority do not and why should those that have no ill effects from taking statins not gain the possible benefits? GPs appear to only remember the last patient with statin side effects - not the majority that take them without any problems.

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  • Vinci Ho

    Reading through the whole 50 odd pages NICE guidance on lipid modification for primary and secondary prevention of CVD, I certainly understand the philosophy behind it although it is very 'proactive' in using statin. Some good points in ensuring people are offered the chance of life style changes first before rechecking the CVD risk 12 months later in primary prevention if patient declines the offer first, random sample is not necessary as we are to use non HDL cholesterol moving away from calculated LDL and clarifying when to monitor LFTs and lipids readings after initiation.
    Problem is still on the 'ambition' of reducing non HDL cholesterol by 40% by 3 months in primary prevention if 10 years-CVD risk is over 10%.Absolutelu not easy to achieve. Also , no one really wants to comment on the true incidence of the side effect of normal CK-aches and pain. Of course, it encourages different doses of same statin and then a statin of lesser potency, before referring to a specialist after trying three different statins. Very diplomatic about the referral with suggestion of a non formal referral e.g. over the phone, Skype , for instance. Practical?

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  • You won't bribe me with payments to hit statin targets eithr. I was involved in an international clinical trial (RESPECT) on a statin. The drug was withdrawn due to deaths caused by high dose statins. I have seen the havoc caused in some patients with this drug, so NICE pressure is not so nice.

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  • This comment has been moderated

  • I agree with Dr. May Carhill when she says the side effects of statins are horrific. Very little is discussed about pancreatitis as a side effect of taking statins and this should be addressed when considering prescribing statins to low-risk patients. As a very healthy, non-alcoholic drinker with a cholesterol level of 5.2, after taking prescribed statins for a few days, I developed a severe form of pancreatitis which could have been fatal. In my opinion more research is required before increasing the prescribing of statins to low-risk patients.

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  • Vinci Ho

    Correction, fasting sample is not necessary.....

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  • The advice from NICE is too simplistic, possibly aimed at increasing statin sales, and as a practice we are not suggesting we follow the 10% rule. Personally I discuss with patients their risk and compare it to the "average" age/sex risk that the Q risk calculator usefully shows. If the average risk was 2% and my risk 10% then assuming this is due to he lipids contribution of my calculation then maybe there is a discussion to be had. BUT if my risk was 25% and average for age/sex 27% then really not sure I would treat myself as my risk is already better than average for my age.

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  • People are aware that the only statins recommended in the guidance are available generically, I assume?
    No money in this for Big Pharma!

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  • With a NNT of 167 for 5years to prevent 1 episode this guidance is bonkers and if you factor in the opportunity costs in terms of GP appointments- sorry but we don't have spare capacity so what should we stop doing to provide all these consultations- it becomes unaffordable and a waste of public money

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  • The problem is that NICE while being National , and certainly an Institute, is not remotely clinical and definitely not excellent. I have visions of Geeks locked in a darkened room devising ever more obscure an inane algorithms which they believe have any relevance to anything other than their own fevered imaginations. Why would any sane person wish to follow their guidance? An example, perchance, of the blind leading the deaf!!!

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  • If I decide to ever "offer" patients NICE guidelines I allways preface it by saying that 75% of the evidence used to by NIOCE to draw up guidance for primary care patients has no basis in primary care. In other words there advice has only an at best 25% relevance to our patients. If that's not enough I then tell them how they recruit their "experts". That's usually enough.
    Paul C

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