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A Resized Statins Image cbAugust 3 2017

Millions of people are not being prescribed a statin despite NICE guidelines indicating they fall into the prescribing category, a new study has found.

Researchers looked at how the 2014 NICE cholesterol guidelines are being applied, in a cross-sectional study using a sample representative of the English population aged 30–84 years.

The study, published in the British Journal of General Practice, aimed to estimate 10-year cardiovascular disease risk of different combinations of risk factor levels using the QRISK2 algorithm. The NICE guidelines were applied to the sample using data from the Health Survey for England 2011.

“Even with optimal risk factor levels, males of different ethnicities would exceed the 10% risk threshold between the ages of 60 and 70 years, and females would exceed the threshold between 65 and 75 years,” the researchers found.

“Under the NICE guidelines, 11.8 million males and females (37% of the adults aged 30–84 years) would require statin therapy, most of them (9.8 million) for primary prevention. Under the new guidelines, 95% of males and two-thirds of females without existing CVD in ages 60–74 years, and all males and females in ages 75–84 years, would require statin therapy.”

Commenting on the research, RCGP Chair Professor Helen Stokes-Lampard said: “We need to get the risk scores right. If we find that all men over 60 and all women over 75 are going to be eligible for statins with new risk scoring, regardless of any other risk factor, then it should ring alarm bells – because it is not clear that every 60 year old man or 75 year old woman is going to benefit from statin therapy.

“As with any drug, taking statin medication has potential side-effects, and taking any medication long term is a substantial undertaking for patients. Many don’t want to take statins once they have learned all the facts – and GPs will respect patient choice.”

“We also need to remember that whilst clinical guidelines are useful tools for GPs when developing a treatment plan for patients, they are not tramlines. GPs are highly trained to prescribe based on the individual circumstances of the patient in front of them – obviously taking age into account, but also any other medication that the patient is using, and all the physical, psychological or social factors that may be impacting their health.

“It’s important that as new evidence becomes available, it is taken on board as guidelines for healthcare professionals are updated – but NHS resources and workforce must also be a factor. We agree with researchers that the workload implications for GPs and our teams with so many people being potentially eligible for statin therapy is enormous, so this must be matched with appropriate resources.”

Dr Mike Knapton, Associate Medical Director at the British Heart Foundation, commented: “There is no question that statins lower people’s risk of heart attack and stroke. This study suggests that an estimated 6.3 million people are missing out on the potential lifesaving benefits of statins. If these people were taking statins, we could not only potentially prevent 290, 000 heart attacks and strokes, but also reduce the burden of these events on both the NHS and people’s lives.”

A couple of days earlier, NICE released a new Quality Standard listing atorvastatin “as the preferred statin to offer patients because it is both clinically and cost effective.”

The recommendation is made in QS5 relating to chronic kidney disease in adults. It expects health professionals to monitor the blood pressure of adults with CKD and be aware of the recommended ranges.

Health professionals should also “check whether adults with CKD are taking a statin, and discuss the risks and benefits of starting statin therapy if not.” Atorvastatin 20mg should be offered and the dose increased if an adequate response to treatment is not achieved and eGFR is 30 ml/min/1.73m2 or more.

Links:
NICE QS announcement        
P Ueda et al. ‘Application of the 2014 NICE cholesterol guidelines in the English population: a cross-sectional analysis’. BrJGenPract 31 July 2017                   RCGP comment                 
BHF comment  
NICE QS5               

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