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NICE statin guidelines – Where’s the shared decision making?

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The long awaited update to the NICE guidance on the use of statins has now been published and the game of ‘spot the difference’ can begin: has the consultation process made any material difference to the draft guidelines published earlier in the year? Well I may not much good at this game, but it looks much the same to me. All the concerns raised about overtreatment seem to have fallen on entirely deaf ears: the CVD risk cut-off remains at 10% and by next April we can guarantee that QOF will have enshrined this with such financial incentives as to make it happen.

In fact, the one difference I have spotted is the upgrading of the new advice for patients with Chronic Kidney Disease (CKD); previously buried in the small print of the main guidance this is now included in the key priorities section. This had passed me by the first time around – I don’t recall anyone reporting it in the news at the time. In case you’ve missed it too, we are now meant to put all our patients with CKD on a statin (yes, including 83-year-old Mrs Jones who has done everything to keep her arteries clean all her life and whose only mistake is to be in possession of a pair of kidneys that have been around for a while).

When asked why this advice had been upgraded in this way, NICE said: ‘It comes from the fact that there was a recognition of the need to prioritise treatment as opposed to risk assessment in CKD3.’ So statins are now a treatment for CKD? Odd that, given that the guidelines say patients with CKD should be treated with statins as they are ‘at increased risk of CVD’. Who’s going to be the first to run a search of all their CKD patients and tell them the good news? Not me, for sure - it’s one in eight of our patients.

And what of patient preference? Will this protect the patient from over-zealous application of these new guidelines? Well Professor Mark Baker of NICE has some reassuring words to say here: ‘We’re not saying that everyone with a 10% or greater risk of CVD within 10 years needs to take a statin. The guideline recognises the importance of choice in preventing CVD.’ The full guideline encourages patient choice, maybe, but who looks at a 302 page document when you can refer to the two page Key Priorities summary? The only mention of patient preference in the summary is with regard to the recommendation to use 80 mg of atorvastatin in patients with established CVD – an indication for which this dose is not licenced anyway.

Not everyone on the panel seems to think patient preference is desirable at all; here’s Liz Clark, a lay member of the panel: ‘One of the key challenges is how to convince people who feel well that they need to make substantial lifestyle changes or that they benefit from lifelong drug treatment.’ In what way is shared decision making a matter of the doctor trying to convince people that they must take medication? She goes on to claim that the patient will be central to the decision-making process, but this will never happen if we continue to use words like that.

One day we will look back at this moment and judge its worth; is this to be one of the great turning points in the drive to reduce heart disease, or a public health disaster as millions of perfectly healthy people have been turned into patients at a single stroke?

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68.

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