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GPs told to ignore NICE statin prescribing guidance in cost-cutting drive

Exclusive GPs have been told to ignore current NICE lipid modification guidelines on statin prescribing in low-risk people, under a cost-saving policy at one CCG.

NHS Stockport CCG has advised GPs should only prescribe statins to people if they are found to be at a 20% or greater risk of cardiovascular disease – and not at the lower NICE-recommended threshold of 10%-20%.

The CCG has also stipulated that GPs should prescribe simvastatin first-line rather than the NICE-recommended lipid-lowering drug atorvastatin, as part of measures to control spending.

NICE condemned the decision, which it said meant people were being denied the opportunity to lower their risk of a disease that 'maims and kills one in three'.

The GPC said that the CCG's decision was 'strange' and 'born out of desperation'.

A recent prescribing news bulletin from the CCG said it had 'made the decision not to implement the NICE Lipid Modification Guidelines 2014', adding: ‘We recommend that patients should be treated if their CVD risk is 20% or above and first line treatment should be with simvastatin 40mg.’

The NICE guidelines state that GPs should offer patients the option of a statin if their 10-year risk of cardiovascular disease is 10% or higher and recommend treatment with atorvastatin as the most effective treatment option because it is 'more potent than simvastatin and less likely to interact with other drugs, as well as being easier for patients to take' .

In a statement to Pulse, NHS Stockport CCG said the decision to block the updated NICE guidance was part of a wider strategy to balance finances.

It said: ‘The CCG was required to make some decisions on savings to achieve financial balance and long term financial health. The plan included a decision to not implement the NICE lipid modification guidelines for primary prevention (CG181) in full.

‘There were extensive clinical conversations at the CCG between the guidelines being issued and the decision in March 2015.’

The statement added that GPs should follow NICE advice around lifestyle modifications – such as diet and exercise – in low-risk patients, but that ‘there is a process to follow for clinical exceptionality and this would be the case for patients where lifestyle modification is ineffective or inappropriate’.

Regarding the advice on what lipid-lowering drug, the CCG said: ‘The decision to recommend simvastatin over atorvastatin was made on clinical cost effectiveness grounds.’

Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee questioned the CCG’s rationale for controlling statin prescribing and warned GPs must still pay attention to the full NICE guidelines.

Dr Green said: ‘So many CCGs are in deficit due to underfunding, and the pressure on them to achieve financial balance is so great, that we are beginning to see some very strange decisions born out of desperation.’

Dr Green added that 'the difference in price between simvastatin and atorvastatin is so low that it would be very difficult to justify not implementing NICE guidance about choice of statin, and GPs need to remember that they have responsibility for their prescribing decisions’.

Professor Mark Baker, director of the centre for clinical practice at NICE said: 'Cardiovascular disease maims and kills people through coronary heart disease, peripheral arterial disease and stroke. Together, these kill one in three of us.

'This decision amounts to denying patients access to the most effective means of reducing that risk. The overwhelming body of evidence supports the use of statins, even in people at low risk of cardiovascular disease. It clearly shows statins are safe and clinically and cost effective for use in people with a 10% risk of CVD over 10 years.

'Our guidance is intended to prevent many lives being destroyed and it offers a major shift in public health outcomes at relatively low cost. In doing so it places patients, not the cost of treatment, centrally in any decision making about their management.'

The row over the 10% threshold

Simvastatin - Statin - Cardiovascular - Online

Simvastatin - Statin - Cardiovascular - Online

Source: Julian Claxton

NICE's decision to recommend prescribing statins to people at the lower 10% risk threshold led to outcry from GP leaders when the guidelines were updated two years ago.

The GPC was among the dissenters, who warned the recommendation could lead to overmedicalisation and divert GPs' precious resources away from their chronically ill patients onto healthier ‘worried well’ people.

NICE had recommended that GP practices should be incentivised through QOF for statin prescribing at the 10% primary prevention risk threshold in all patients newly diagnosed with diabetes or hypertension.

However, it later rolled back on the recommendation.

 

 

Readers' comments (23)

  • Have already been discussing this with patients.Patients are not keen on statins at the lower risk ranges.At the lower risk ranges I would definitely not take them either.

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  • NICE needs more front line GPs on its panels. They currently haven't a clue about GP land.

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  • Good for them.

    While I "offer" statins at 10% risk, very few patients take me up on it. This is probably because I word the offer in a way that reflects my own belief that statins at 10% risk are a waste of time.

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  • What's the NNT with statins at 10% ?

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  • We all know statins at 10% is stupid but to not offer them against NICE guidelines is very risky nowadays. Guidelines ceased to be guidelines long ago and patients will use them to sue you when they have a heart attack or stroke and the CCG is not going to pay your bill.

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  • When you do the calculations with patients at 10% risk, most of them feel there is such a tiny benefit to them personally (given that you can't really extrapolate from a population to an individual) that the majority say no.

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  • As a patient myself with a cholesterol of 7.7 but a Q-risk less than 10% but a terrible family history my cardiologist is recommending I take a statin but my GP colleagues don't. Whose advice would you take?? Do I wait for the first (and possibly last!) MI or do I start preventative measures now?

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  • How safe are NICE Guidlines 50% of clinical trials most of them showing medicines in a negative light arent published or have their end points changed because they are not going to show their original end points in a favourable light as far as drug companies are concerned

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  • Re previous comment would the editor/pulse be prepared to seek expert opinion on this and the overall safety of NICE Guidelines based on this fact

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  • Cholesterol over 7 I would always reccomend statins whatever the Q risk is

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  • I read with dismay the comments of fellow colleagues.
    Statins are highly effective at reducing risk and are very safe.
    Routinely drugs are given for the mythical disease of "hypertension", and to patients with even lower risk than the 10-20% 10year risk level, even though they give less benefit and have more side effects than statins.
    And for CCGs that think that Stockport CCG is doing something sensible to save money, they should go read the economic analysis of the HPS and WOSCOP studies. Both show statins saving money by reducing hospital costs.
    Every £1 spent on statins in this group probably saves £8-10.

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  • We have now dropped into Alice in Wonderland world. The way out is pretty obvious. State pays for secondary prevention, individuals pay for primary prevention. Nothing else is going to work I'm afraid.

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  • The NICE guidance actually states that lifestyle changes should be advised above 10% risk and then consideration of a statin if that doesn't work. Most patients take it as a 'wake up' call to do something about their risk factors and I rarely need to prescribe statins to this group in my clinic.

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  • @Joe Mcgilligan | GP Partner|02 Jun 2016 11:48am

    QRISK does not take into account conditions like Familial Hypercholesterolemia and hyperlipidaemias. Cholesterol 7, LDL 4 and Chole:HDL ration of 5 are highly suggestive of genetic factors to which clinical tools are blind to.

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  • At 10% risk and with claimed 25% relative risk reduction, number needed to treat is about 50. While at 20% risk and same rrr, nnt is 20.

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  • Joe Mcgilligan | GP Partner02 Jun 2016 11:48am

    If I recall correctly Qrisk results can vary dramatically depending on your post code alone. I I were youi, high total cholesterol & bad FH - I'd take a statin

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  • For a moderate intensity statin 33 patients need to be treated to prevent 1 CVD event over a 10 year period. 1/33 gives you your absolute risk over 10 years = 0.03%. If you have a 10% chance of having a CVD event over the same 10 year period = 1/10 x absolute risk (0.03) = 0.003 is the absolute risk reduction for someone with with a 10% QRISK2 taking a moderate intensity statin that gives around a 40% reduction in LDL. Not sure if I did the math right or not.

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  • I work as a GP in Stockport and this guideline has been there for a few years now, it is not news.

    The guideline is total nonsense. A high proportion of patients who have a QRISK more than 20% are already on amlodipine, meaning they end up receiving a very low dose of simvastatin, which is significantly less effective than atorvatatin. The cost savings are minimal.

    If someone had a massive MI,and they had a QRISK of 18% and an LDL of 3.9 and you had deprived them of a statin, you would be on very thin ice from a medicolegal point of view. I choose to ignore these local guidance and go through the pros and cons of taking a statin with the patient in front of me, based on their individual circumstances. We then come to a shared decision. If they want a statin then they get atorvatatin 20mg. I have never had anyone from the CCG say anything and you have to ask what is the point of local guidelines like this, when they arw trumped by national ones? What a waste of everybody's time!

    The biggest scandal is the imbalanced negative press regarding statins in the national papers. I'm not saying they are perfect (they're clearly not), but used correctly they prevent people from having heart attacks and strokes. This wastes a lot of all our time and they should be held accountable for this.

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  • I think the imperial Indian study and recent met analysis showed benefits from statin
    Even the Japan study reduced deaths and morbidity
    No doubt start early and don't wait for clogged arteries

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  • Stockport GP use atorvastatin with amlodipine

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  • Yes simvastatin gave statin a bad name

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  • Sirs,
    I have commented on other forums about these matters, that is, conflict of interest between various authorities about prescribing. In this specific matter, I feel that NICE has more weight than the CCG. NICE is recognised world wide for its recommendations, where as the CCG is nowhere in comparison. Furthermore, READ YOUR TERMS OF SERVICE and understand what is required of you. GPs are not servants of the CCG nor of NICE. We have to provide a service for the benefit of the patient and be prepared to defend our decisions if a justification is required.
    So, if you read widely, and understand the subject, do your bit. Remember, if questioned, it will be the GP and not NICE or the CCG.

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  • Joe, it sounds like you have familiar hypercholesterolaemia and you should definitely be on a statin and if you have any children( even if young) that should be tested. I have two doctor friends like you who each has one child being treated with a statin

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