Should GPs prescribe statins at NICE’s proposed new threshold? Yes
Professor Mike Kirby argues that a lower threshold is practical and will save lives
NICE’s proposed changes to its guidance on prescribing statins will mean more work for GPs. But treating people who have a 10% 10-year risk of cardiovascular disease will be cost-effective, the institute says. It is not out of step with other international guidelines, and a recent updated meta-analysis of 18 trials showed primary prevention with statins reduced coronary heart disease by 27% and all-cause mortality by 14%.1
My own father and his brother died of cardiovascular disease in their late forties. At the time there were no statins, no ACE inhibitors and no calcium-channel blockers. I am now in my sixties, on a statin, side-effect free – and still alive.
Critics often point to the long list of associated side-effects. But a recent substantial analysis of placebo-controlled randomised trials of statins found only a minority of side-effects reported by patients were actually attributable to the drugs.2 Almost all the side-effects reported in these trials occurred as often when patients were administered placebo. An increased risk of diabetes with statins was seen, though, in two of the trials.
It is critical that risk is correctly calculated; if we get it wrong the benefit-to-risk ratio of treatment becomes too small.
It is also important that the additional work is adequately funded. Although some screening, treatment and monitoring can be done by nurses, there will be a significant cost to GP practices.3
CCGs will need to offer enhanced QOF payments or develop LESs that adequately support practices in this work, and special attention needs to be paid to deprived communities, ethnic groups and those with a mental health diagnosis, who are at greatest risk and need most support.
Professor Mike Kirby is a professor of medicine at the University of Hertfordshire and a GP in Letchworth. He is editor-in-chief of the Primary Care Cardiology Journal
1 Taylor F, Huffman MD, Macedo AF, et al. Statins for the prevention of cardiovascular disease. Cochrane Database Syst Rev 2013; DOI:10.1002/14651858
2 Finegold JA, Manisty CH, Goldacre B, et al. What proportion of symptomatic side-effects in patients taking statins are genuinely caused by the drug? Eur J Prevent Cardiol 2014; DOI:10.1177/2047487314525531
3 Handler C, Coghlan G. Preventing Cardiovascular Disease in Primary Care. Oxford: Radcliffe; 2008