NICE under pressure to revise lipid guidance
By Rashmi Wadehra
Institute criticised for vague advice and 'tabloid medicine'
NICE is under pressure to revise its controversial lipid modification guidance after being accused of having muddied the waters with its 'ambiguous' initial draft.
A series of leading cardiovascular bodies have submitted evidence criticising the institute for not setting a primary prevention target and for not being clear if it was setting a secondary prevention target or not.
The draft recommends GPs titrate up treatment for secondary prevention in patients whose cholesterol remains over 4mmol/l – but then insists this does not constitute a target.
Dr Stewart Findlay, who has been involved in submitting evidence for the Primary Care Cardiovascular Society, said he had been 'disappointed' by the draft.
'NICE is not clear in its primary care targets. It says you should up the medication of patients if their cholesterol and LDL reaches 4 and 2 but it doesn't tell us it should be the target. The wording is so vague and NICE won't come off the fence.
'If people at risk of cardiovascular disease merit treatment, then primary care prevention needs to give patients a target that works as an incentive.'
Professor David Wood, chair of the Joint British Societies, also called for a target, saying: 'NICE has created targets for other risk factors. Targets act as a guide to judge the intensity of treatment.'
Professor Wood stressed that NICE would need to provide more information on the cost-effectiveness of prevention.
'There is a target for secondary prevention but none for primary prevention. This needs to be addressed. If treating to target is less cost-effective than the "fire and forget" strategy, it is important for physicians to implement treatment accordingly.'
The Association of Clinical Biochemistry is also preparing its response to the NICE consultation. Similar fears were echoed by its spokesperson Professor Ian Young, consultant clinical biochemist at Queen's University Belfast.
'The secondary prevention targets are ambiguous,' he said. 'There is also an inconsistency between what is expected in the QOF and the NICE guidelines. Again, cholesterol targets are different. It's an inconsistency that should be addressed.
'Finally, the guidance focuses exclusively on cholesterol. It should include triglycerides and HDL cholesterol too.'
Dr John Pittard, a GP in Staines, Middlesex, and national service framework adviser for coronary heart disease, has branded the draft guidelines as 'tabloid medicine'.
'Similar to the quality and outcomes framework that is so politically correct, there is no mention of age. There are vested interests financially and politically behind this NICE guidance,' he said.
NICE said it would release a response once the two-month consultation period ended.
How critics of the guidance are lining up
Primary Care Cardiovascular Society
• NICE is sitting on the fence; targets are needed as incentives for patients
Joint British Societies
• Inconsistency on targets
• Targets are needed to judge how intensive treatment should be
• Evidence is required to compare different treatment strategies
Association of Clinical Biochemistry
• Secondary prevention targets are ambiguous
• Guidance should look at triglycerides and HDL tooDr Stewart Findlay: disappointed by the draft guidance Dr Stewart Findlay: disappointed by the draft guidance