GPs to give statins to millions more patients after major NICE rethink

GPs are set to prescribe statins to millions more patients, after NICE advised lowering the threshold at which patients are treated to prevent cardiovascular disease.

Statins: NICE advice change could lead to wider use (photo: James King-Holmes/Science Photo Library)
Statins: NICE advice change could lead to wider use (photo: James King-Holmes/Science Photo Library)

Patients with a 10% or greater risk of developing cardiovascular disease in the next decade should be offered statins, the institute said - half the risk level currently used to steer treatment.

The latest risk-assessment score, QRISK2, will become the standard tool to assess most patients, while atorvastatin is favoured over simvastatin for primary prevention.

It marks a significant change to NICE’s lipid management advice, last updated in 2008.

Experts welcomed the move and said the shift was largely due to the falling price of statins, in particular atorvastatin, the patent for which expired in 2012.

When the risk threshold was last lowered, from 40% to 20% in 2007, a further 5m patients became candidates for statin treatment.

While NICE has not yet published an official estimate of how many more patients could be prescribed the drugs under its latest advice, a substantial increase in the UK's 7m statin users is expected.

Under the draft guidance, now released for consultation, GPs should use the QRISK2 tool to assess cardiovascular risk in most patients aged 40-74 identified as potentially being at high risk. It replaces previous advice to use any ‘appropriate’ risk calculator.

The 10-year risk threshold for considering statin therapy will fall from 20% to 10%.

However, the tool is not recommended in patients with diabetes, CKD stage 3 or greater, pre-existing cardiovascular disease or in those at high risk from inherited cholesterol disorders. The tool will also underestimate risk in patients with underlying conditions such as HIV or serious mental health problems, NICE said.

Greater health promotion role for GPs

Falling statin costs are reflected in NICE’s advice to prescribe atorvastatin 20mg for primary prevention instead of simvastatin 40mg, as was previously recommended. Patients with existing cardiovascular disease, type 1 or type 2 diabetes should start on atorvastatin 80mg.

NICE has scrapped previous advice to use statins with a low acquisition cost, saying this is ‘no longer relevant given cost effectiveness of using different statins’.

GPs will also be encouraged to give more healthy eating advice to at-risk patients, including eating five portions of fruit and vegetables per day and what cooking oil to use.

Lower statin costs a key factor

Professor Mark Baker, director of the Centre for Clinical Practice at NICE, said statins should now be offered to many more people. ‘The effectiveness of these medicines is now well proven and their cost has fallen,’ he said.

‘Doctors will need to make a judgment about the risks to people who have a less than 10% risk of developing cardiovascular disease and advise them appropriately.’

Professor Peter Weissberg, medical director at the British Heart Foundation, said: ‘The current guidance weighed the benefits of taking a statin against what was then the considerable cost to the health service. This pragmatic decision made sure that those of highest risk benefitted.

‘However, as most people who have a heart attack or stroke have average cholesterol levels and since statins are now much cheaper it makes sense to reconsider the threshold.’

Cardiovascular disease kills 180,000 people a year in the UK. The NHS currently spends £450m a year on statin therapy.

Berkshire GP Dr George Kassianos welcomed the moves to lower the risk threshold for statin therapy and switch to atorvastatin, 'which exhibits a much better side effect profile than simvastatin', he said.

He said NICE was now 'on the right track' on lipid management, but he questioned why it had taken NICE 'so long to see the obvious'.

North Yorkshire GP Dr Terry McCormack, secretary of the British Hypertension Society, was more cautious. He said: 'The key issues are how do we direct therapy at the correct people and particularly how do we include the young people with high lifetime risk. A 10% threshold will be very controversial and personally I feel using relative risk as well as absolute risk is important.'

The consultation on NICE's draft guidance runs until 26 March.

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