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NICE is not operating from an ivory tower



New draft guidance from NICE does, for some, reopen a long-running argument about the merits of primary prevention of CVD with statins. But it’s rather less clear how it raises ‘fundamental questions’ about NICE’s role and its input from GPs, as a recent Pulse editorial has claimed.

As Pulse has acknowledged, two GPs sat on the group that drew together the lipid modification guidance and that is far from being an insufficient level of input.

Pulse accuses NICE of operating from an ‘ivory tower’, producing guidance in a non-transparent way. This is clearly not the case. Our guidance production processes have always been based on key principles that define how we work. These include transparency, inclusivity, independence, scientific rigour and timeliness. The application of these principles has been fundamental to our success and they are valued highly by our stakeholders. Rather than criticise the NICE guideline development process indiscriminately, perhaps Pulse would like to take a more considered approach and provide us with the specific detail on which his charge is based.

As to the draft guidance itself, the evidence clearly demonstrates that there is no credible argument against the safety and clinical effectiveness of statins. The reduced price of statins adds cost-effectiveness to their use at a lower threshold for CVD risk. But let’s be clear here: the guidance is not advocating that statins should be prescribed as a matter of course for people with a CVD risk that is equal to or greater than 10% over 10 years.

Statins are not a proxy for the lifestyle adjustments people with that level of risk need to make, and the guideline addresses this comprehensively. It is also essential, as I have said for many years, that medicine is something that doctors do with patients rather than to patients. Discussion of pros and cons of any therapy is a vital part of the decision-making process.

We are currently also developing guidance on medicines optimisation and multiple morbidities which will help to address the entirely legitimate arguments made by respondents about the limited attributable benefit in some patients where their risk is dominated by other factors. But even they can reduce their risk by taking statins. For many very old people, statins may be of greater benefit than treating moderate hypertension.

The draft guidance on lipid modification is out for consultation. We stand by the scientific legitimacy of the proposals but recognise that patient choice offers alternative strategies for reducing the risk of CVD and we anticipate stakeholder responses with keen interest.

Professor David Haslam, chair of NICE