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Time to step up statin switching

There is work to be done to shift as many patients as possible to low-cost simvastatin, writes Dr James Moon

There is work to be done to shift as many patients as possible to low-cost simvastatin, writes Dr James Moon

At £600m, statins are the biggest single area of drug spending in the NHS, with GP prescribing growing 30% a year. NICE advises using a statin with a low acquisition cost, but with five to choose from, a range of doses and different evidence, efficacies and interactions, which should a GP opt for?

Around 80% of patients are on low and intermediate doses – simvastatin 40mg or less or atorvastatin 20mg or less. Some receive intensive statin therapy, but they usually have severe dyslipidaemias or established cardiovascular disease.Simvastatin was a blockbuster drug until its patent expired in 2003. After the generics arrived the price fell drastically and simvastatin 40mg is currently just £3.80 per month. The cost of atorvastatin has remained unchanged, at £18.03 for 10mg and £24.64 for 20mg, with the price unlikely to drop until its patent ends in 2011.

There has been a revolution in GP statin prescribing in the last 18 months, with 2006 data showing an 18% reduction in use of atorvastatin 10mg and a 64% increase in use of simvastatin 40mg. This change will save the NHS £1bn by November 2011.

But there is more work to be done. As many as a million people remain on low-dose atorvastatin and there is large countrywide variation in generic statin prescribing. In some areas, the improvements are startling – in Essex, Redbridge PCT increased generic statin prescribing rates by 25% in the last quarter. Switching patients from atorvastatin 10 or 20mg to simvastatin 40mg will save £1,000 over five years at an individual level, or a further £1bn nationwide.

But are the effects of simvastatin 40mg the same as low-dose atorvastatin? The short answer is yes. When simvastatin 40mg is used, the effect on LDL cholesterol is slightly greater than atorvastatin 10mg and slightly weaker than atorvastatin 20mg. But while there is strong clinical evidence for simvastatin 40mg and atorvastatin 10mg, there is none for atorvastatin 20mg.

Serious side-effects with any low-dose statin are rare and since simvastatin and atorvastatin share similar metabolism, interactions are broadly the same. As for the QOF, switching to simvastatin 40mg does not significantly affect LDL cholesterol and has been shown not to affect the ability to get cholesterol to 5 and 3.

Some patients do require intensive statin therapy, which targets for the use of low-cost statins might seem to ignore. The way round this is to aim switching at the branded, expensive, usual-dose statin, leaving intensive statin therapy alone. Saving money by using simvastatin 40mg for primary prevention leaves more funds to prescribe high-dose atorvastatin for secondary prevention and other high-risk patients.

Bear in mind that there is no evidence for use of intensive statin therapy in low-risk patients. Statin use in such circumstances is a classic example of the law of diminishing returns.

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