GPs set to defy NICE over cholesterol

Titrating up simvastatin could cause side-effects including sleeplessness or lethargy.

GPs look set to abandon NICE guidance on lowering cholesterol levels amid concerns over possible side effects.

The guidance, out last week, recommends that GPs aim for targets of 4mmol/l for total cholesterol and 2mmol/l for LDL cholesterol for the secondary prevention of cardiovascular disease (CVD) using 80mg simvastatin.

But Dorset GP Dr Graham Archard, who has an interest in CVD, warned: 'If you double up the dose of simvastatin you do not get much more lipid lowering but a lot more side-effects. These can include sleeplessness, lethargy and a feeling of being unwell.'

The majority of GPs would suggest that a change to a lower dose of a different statin would be better, said Dr Archard.

Dr Bill Beeby, chairman of the GPC prescribing committee, said: 'Using 80mg simvastatin is not without its risks and is more likely to cause muscular problems than using atorvastatin. Patients on simvastatin would require monitoring.

'I am not sure that we can achieve the cholesterol targets using simvastatin alone.

'We will have to add secondary agents such as atorvastatin, rosuvastatin or ezetimibe in order to achieve the targets.'

Dr Beeby added that the decision to use generic simvastatin was probably a 'cost saving measure' by NICE.

Dr Rob Butler, a consultant cardiologist at the University Hospital of North Staffordshire in Stoke, advised atorvastatin use rather than titrating up simvastatin.

Dr Terry McCormack, chairman of the Primary Care Cardiovascular Society and a GP in North Yorkshire, said evidence backed the use of a high intensity statin like atorvastatin over simvastatin.

'NICE has fudged together a lot of issues to produce some confusing guidance,' he said. 'They are suggesting that we aim for targets of 4mmol/l and 2mmol/l but then include an audit target of 5mmol/l.

'I do not believe that many GPs will use this guidance at all.'

GPs will continue to stick to the quality framework targets of 5mmol/l for total cholesterol and 3mmol/l for LDL cholesterol that they are paid to achieve, he added.

NICE lipid modification guidance 2008

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