NICE guidance confirms U-turn over 10% statin threshold for GPs

Patients with a 10% cardiovascular risk should not automatically be prescribed statins, according to a NICE quality standard that backs down from an earlier statement that the QOF should 'mandate' GPs to offer the treatment at this threshold.

The new NICE quality standard emphasises that GPs should focus on ‘lifestyle changes’ in patients with cardiovascular risk before offering statins. Recommendations earlier in the year suggested GPs should blanket-prescribe the treatment to newly-diagnosed at-risk patients.

NICE initially approved a QOF indicator back in June that would pay GPs for every patient put on statins who had been diagnosed with hypertension or diabetes and had a QRISK2 risk score over 10%. This proposed indicator looked set to be among those to be considered by NHS England for inclusion in the next GP contract.

In a controversial move, wording of the indicator meant that GPs would only get paid if the patient was ‘currently [being] treated with statins’ – a recommendation that went beyond NICE’s own guidance, which stipulates statins need only be ‘offered’ at this threshold.

NICE later decided against putting this forward in the finalised menu, following complaints from GPs who said the decision would threaten the credibility of the QOF. A GPonline poll revealed that two thirds of GPs thought NICE was wrong to approve the indicator.

Statins threshold

NICE Indicator Advisory Committee chairman Dr Daniel Keenan told GPonline at the time that ‘it would be crazy’ to not base QOF indicators on the current evidence, which showed that all patients with a 10% risk or higher should be taking statins.

He said: ‘The truth is I am not sure why there is so much [opposition from GPs]. Patients today are being treated at the 20% level all over the place, there's virtually no change.

‘If the risk algorithm shows they have a 10% risk then they should be given a statin, that’s the evidence and that’s the guidance.’

But at the release of the new quality standard, NICE distanced itself from the suggestion that GPs should blanket-prescribe the treatment.

NICE recommendation

Professor Gillian Leng, NICE deputy chief executive said: ‘Like the NICE clinical guideline on which this quality standard is based, we’re not saying that everyone who is assessed as having a 10% or greater risk of developing CVD within 10 years should be given a statin. Before that happens there are many things that people can do to reduce their risk, and the standard is clear that making changes to lifestyle is the first consideration.’

Dr Michael Rudolf, chairman of the committee that developed the standard, said: ‘In addition to a number of lifestyle modifications, other possible causes of increased risk of CVD or abnormal lipid levels – for example excess alcohol, uncontrolled diabetes, and some diseases of the thyroid, liver or kidneys – need to be identified and treated before starting a statin.

‘The quality standard also highlights the importance of a documented discussion between patient and healthcare professional about the potential risks and benefits of starting treatment, so that a fully informed, shared decision can be agreed before starting a statin.’

Photo: iStock

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