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Coronary heart disease

DTB simvastatin recommendation limiting

From Mrs J. A. Harding, MRPharmS

The recommendation by the Drug and Therapeutics Bulletin (DTB) to use simvastatin for routine first-line therapy for the prevention of coronary heart disease (CHD) events (PJ, March 24, p383), although theoretically correct, can be limiting in practice.  

Atorvastatin has the greatest lipid lowering effect at the maximum licensed dose, followed by simvastatin, but not all patients require this level of treatment to reduce their cholesterol to the levels required by the national service framework for CHD.  Primary care groups, like my own, are under significant financial pressure to achieve NSF recommendations with limited budgets, and prescribing guidelines need flexibility to enable prescribers to select the most cost-effective statin for each patient.

In September, 1999, using clinical evidence and cost-effective models, a seven-practice single contract PMS pilot within the PCG developed joint guidelines for statin prescribing, with the choice among three statins based on the degree to which cholesterol needed to be lowered. Following this, we audited patients in one of our practices, and switched about 100 patients from low doses of simvastatin and pravastatin to fluvastatin (40mg daily).  No major problems were noticed, and only two patients needed to be changed back.

The average cost per prescription decreased by 25 per cent following the change. A comparison of prescribing data three months before and after the change showed that the overall cost of statin prescribing in this practice had reduced by 5 per cent, while items prescribed increased by 50 per cent.

It is now 18 months since we implemented this change. Following publication of the NSF on coronary heart disease in March last year, the prescribing guidelines were altered to take account of the more stringent targets, with fluvastatin XL (80mg) now recommended for those with pre-treatment total cholesterol levels of 7mmol/L or less. Nearly 125 patients are now prescribed fluvastatin at the study practice, other practices have subsequently switched appropriate patients, with few difficulties, and new patients also receive fluvastatin if they fit the guideline criteria. Each of the three statins in the guideline now has a 30 per cent share of the total prescribed items, but fluvastatin only represents 19 per cent of the total costs.  

The successful implementation of changes based on a prescribing guideline is dependent on the commitment of primary care pharmacists to ensure that accurate and appropriate adjustments are made.

I would not advocate a policy of swapping simply to save money, but strict adherence to the DTB recommendation would deny us the flexibility to use a drug that is clinically effective for the patient and cost-effective for the PCG.

Jenifer Harding
Primary Care Pharmacist
Rowley Regis and Tipton Primary Care Group, West Midlands

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