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Gold, incentives and meh

NICE lipid guide takes middle path

The Institute's long awaited guidance takes very different approaches to primary and secondary prevention

By Lilian Anekwe

The Institute's long awaited guidance takes very different approaches to primary and secondary prevention

It's finally here. The hotly anticipated, suitably controversial NICE guidance on lipid modification has arrived – in draft form at least.

Much has been said in the run-up to this document. Doctors predicted that a recommendation for at-risk patients to be systematically screened would swamp practices with work.

Others cautioned that the guideline would herald mass medicalisation, while some feared that it would ramp up pressure to use cheap generic drugs.

At first sight, it appears the guideline is reassuringly pragmatic for GPs. NICE recommends they lower total and LDL cholesterol to 4 and 2mmol/l respectively for secondary prevention and, in a nod to the quality framework, there is an 'audit' total cholesterol level of 5mmol/l.

No targets have been set for primary prevention. GPs should use the lowest acquisition cost drugs, which should be titrated up in patients who are not initially controlled to 4 and 2.

Stepping back from targets for primary prevention and moving towards risk assessment, NICE proposes that GPs 'regularly and systematically review' all patients over 40, but shies away from going for an all-guns-blazing cardiovascular screening programme.

Primary prevention

Dr Stewart Findlay, treasurer of the Primary Care Cardiovascular Society and a GP in Bishop Auckland, County Durham, says NICE should have set a primary prevention target.

'It's confusing. GPs are used to being given targets and having priorities within which to work. I'm sure most will adapt but I can't understand why they are not suggesting something we can measure ourselves against.'

He is also concerned the 5mmol/l 'audit target' could give budget-setters an excuse to pull back from paying for intensive therapy. Perhaps unsurprisingly the drug companies are, cautiously, in agreement.

A representative for Pfizer says the company was surprised by what it describes as the 'unprecedented' decision, adding: 'A lot of people would have welcomed targets and it's a brave move by NICE. If it's successful, that's a good thing, but in the absence of targets that's going to be difficult to show.'

But other GPs think NICE was right to steer clear of targets. Dr John Ashcroft, CHD lead for Erewash PCT and a GP in Ilkeston, Derbyshire, thinks 'there's no need to waste GPs' or patients' time by keeping going back and checking cholesterol levels'.

GPs could still deliver health gains for patients at no overall cost as long as the lowest acquisition cost statins were prescribed, he said.

4 and 2 vs 5 and 3

The big question leading up to publication of the guidance was how far GPs should drive down lipid levels. NICE has failed to conclusively settle this point.

Dr John Pittard, a GP in Staines, Middlesex, and CHD lead at North Surrey PCT, thinks the guidance is 'fair enough' on the whole, as 'everyone is moving towards 4 and 2, and secondary prevention people are quite high-risk patients'.

But he adds it may send out the wrong message. 'The audit standard and treatment targets should be unified. It sends the signal that it's important but we can take our foot off the pedal – "aim for 4 and 2 but don't pursue anyone below 5 and 3".'

Dr Pittard also feels NICE has missed an opportunity to give everyone the chance to lower lipid levels as much as possible. He doesn't see why primary care shouldn't set its own target – to reduce 60% of patients on statins to 4 and 2, for example.

But to decide whether or not this is a realistic target, GPs would first need to gauge the extent of the problem.

Screening or reviews?

Although NICE stopped short of advising GPs to start screening at-risk patients, the influence of public health experts is writ large across the guidance.

Many may find it hard to differentiate between this and the long-promised, longer-delayed official cardiovascular risk assessment programme.

Even though this is not 'screening', it does seem likely that it will trigger a rise in the use of statins – albeit not as great an increase as if 4 and 2 targets had been adopted for primary prevention as well.

But Dr Ashcroft has a warning for GPs: 'Let's not kid ourselves – it's still a huge amount of work, about 7.5 million people. But it's a good step forward.'

the ups and downs of lipid lowering Varying cholesterol targets

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