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‘The 10% risk threshold has no credibility within the profession’

Minimal change in statin uptake in the past year shows GPs have little faith in NICE’s decision to lower the primary prevention threshold, argues Dr Rubin Minhas

These data suggest prescribing of statins for primary prevention has changed little since NICE published the new lipid guidelines last year. Any significant increase in uptake of statins among those at lower risk would have been reflected by a major increase in the total quantity of all statins prescribed, but this has actually risen less in the past year than it did in preceding years.

The modest increase in atorvastatin 20mg and 80mg prescriptions is likely to be largely explained by a further shift away from simvastatin 40/80mg now that this switch is endorsed by the guidelines. This is underlined by the continuing fall in the amount of simvastatin prescribed. Meanwhile, concerns over rhabdomyolysis with high-dose simvastatin have also recently triggered a major sideways switch to atorvastatin, while rosuvastatin usage is actually falling.

In my experience, primary prevention with statins at the 10% 10-year cardiovascular risk threshold has no credibility among clinicians, and CCGs are even encouraging GPs to de-prescribe in low-value clinical scenarios such as this. The overall trend reflects this wider move towards de-prescribing, which is really an antidote to the overzealous prescribing of medications in guidelines driven by special-interest lobbies.

Dr Rubin Minhas is a GPSI in cardiology in Kent and adviser on the NICE 2008 lipid modification guideline

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Readers' comments (5)

  • Vinci Ho

    This demonstrates how distant NICE ,as an establishment , is away from front line grassroot GPs(as like other establishments). Its track record is full of contentious issues:
    Statin in 10% CVD risk , anti-viral as a prophylaxis for index case(s) of influenza in an institution , drugs recommend in type 2 diabetes, a recommended thiazide not even available in the market for hypertension , 'new' but impractical criteria of diagnosing asthma in primary care etc.
    It bets the question of what is the mechanism(and any cost involved) NICE generates its guidances on regular intervals and the inclusion of opinions from frontline primary care clinicians. GPs may be 'just' generalists but we want to serve the principle of common sense and be 'real' to our patients.
    But then again, what do I know? I am only an ordinary GP under the scrutiny of GMC and CQC all time ........

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  • Ivan Benett

    I'm surprised to hear this doctor rubbish the updated NICE guideline. Things have moved on since 2008 It is not the case that NICE are suggesting prescribing statins for people at a 10yr risk. Rather, this is the overall 10 yr risk when we should be starting the discussion about reduction in risk factors.
    In any case NICE guidelines aren't mandating the prescribing of statins. In fact if you actually look at the guideline, and I'm surprised Dr Minhas does't seem to have kept up to date on the latest 2014 guideline, it is clear that lifestyle changes should be encouraged first, and then review risk.
    The exceptions are existing CVD (secondary prevention), Type1 diabetes and CKD.
    If QRISK2 still 10% in 10years, have a discussion and make a shared decision, taking into account potential benefit, possible harm, cost and individual autonomy. In fact, just like every other clinical decision we make with our patients.
    The American's have gone for a 7.5% 10 yr risk as the threshold for having the discussion about intervening to reduce CVD risk.
    This necessarily means that some will choose to decline the offer of medication, and that's OK so long as patients are given the opportunity to make an informed decision.
    Rubbishing the NICE advice just because you don't like it is as idiotic and following it slavishly.
    I know Pulse have a vested interest in polarising views, but really medicine is much more subtle than tabloid headlines can convey. Especially evidence based medicine.
    See the excellently well written and crafted NICE Quality Statements on this issue. Some of Britain's top clinical brains have gone in to writing them!

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  • Dr Bennett, I think you may be missing the point. A threshold of 10% or even 7.5% ten year risk is fine for triggering discussion about lifestyle modification. The concern is that it is too low for considering statins in otherwise healthy people.

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  • I feel that the whole 10% risk measurement is too crude a test. If I had a 9% risk at age 25 I would be a high risk candidate for future vascular disease yet would be ignored. Yet if I had a miraculously low risk of 11% at age 70 I would be encouraged to take a statin.
    We need to change to a more complex centile based system to get rid of these flaws.

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  • I feel that the whole 10% risk measurement is too crude a test. If I had a 9% risk at age 25 I would be a high risk candidate for future vascular disease yet would be ignored. Yet if I had a miraculously low risk of 11% at age 70 I would be encouraged to take a statin.
    We need to change to a more complex centile based system to get rid of these flaws.

    Unsuitable or offensive? Report this comment

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