Tough new targets on lipids after NICE adopts JBS line
By Nigel Praities
GPs will be expected to hit tough new targets for lipid modification after NICE moved in line with the Joint British Societies in its recommendations for secondary prevention.
The institute's guidelines, published this week, recommend GPs should aim for targets of 4mmol/l for total cholesterol and 2mmol/l for LDL cholesterol in patients with established CVD.
The targets present a challenge to practices, with the guidance document itself admitting half of patients with CVD would not achieve a total cholesterol of less than 4mmol/l, and that an audit level of 5mmol/l ‘should be used to assess progress'.
The guidance had a mixed reaction from GPs, with some warning the targets would result in ‘enormous' extra workload, while others said they did not go far enough. There was also controversy over the recommendation for primary prevention, with NICE ruling there should be no target and GPs should use only 40mg simvastatin.
Dr Rubin Minhas, a member of the guideline development committee and a GP in Gillingham, Kent, said the guidelines included an audit target to allow GPs to individualise treatment: ‘Many people won't be eligible for high-dose statins, while for others fine-tuning the dose is all that's needed. An audit target is the fairest guide.'
But Dr John Pittard, a member of the Primary Care Cardiovascular Society and a GP in Staines, Middlesex, said the audit target was a ‘cop-out' and that GPs could achieve tough targets in the majority of patients given the right drugs.
‘It comes from political and financial interference from people who are not responsible for individual patients. All patients should be titrated to 4,' he said.
Dr Pittard warned GPs would come into conflict with PCT targets for generic statin prescribing, with more intensive and expensive treatments required.
Professor Neil Poulter, professor of preventive cardiovascular medicine at the National Heart and Lung Institute and an author of the Joint British Societies' guidelines, said it was ‘not realistic' to hit targets with just simvastatin. ‘There seems to be an aversion to use the statin with the most evidence – atorvastatin – purely based on cost.'
But Dr Malcolm Kendrick, a GP in Cheshire and author of The Great Cholesterol Con, warned: ‘It will be an enormous amount of extra work and a drug-induced idiopathic disaster.'NICE guidance on lipids
• Framingham 1991 10-year risk equations should be used to assess CVD risk with adjustments for ethnicity and family history
• Primary prevention:
Simvastatin 40mg recommended for adults with 20% or
greater 10-year risk of developing CVD
• Secondary prevention:
– Initiate on simvastatin 40mg
– Consider increasing to simvastatin 80mg or a drug of similar efficacy and acquisition cost if total cholesterol >4mmol/l or LDL cholesterol >2mmol/l
– Audit level of total cholesterol of 5mmol/l should be used to assess progress in populations or groups of people with CVD
Source: NICE guidelines on lipid modification