The Pharmaceutical
Journal Vol 266 No 7152 p815-820
June 16, 2001
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The Pharmaceutical
Journal Vol 266 No 7152 p815-820 |
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RPM |
Coronary heart diseaseUse of statins in Airedale PCTFrom Mr C. D. Booth, MRPharmS, and Mr J. A. Pearse, MRPharmS We would like to support the comments made by Duncan Petty with regard to the cost of low density lipoprotein (LDL) cholesterol reduction by various statin drugs (PJ, May 19, p678). The table he produced was useful. However, it should be pointed out that the last column of the table actually shows the cost per percentage LDL reduction per 28 days and not per day as stated. In addition, fluvastatin XL 80mg is now available, which is reported to produce a 35 per cent reduction in LDL, at a cost of £16 per 28 days. This is therefore theoretically the most cost-effective agent at a cost of £0.46 per percentage LDL reduction per 28 days. Our own local primary care trust guidelines acknowledge the fact that the use of cerivastatin 400µg daily or fluvastatin XL 80mg daily are the most cost-effective ways to meet the national service framework target. These are not licensed starting doses, however, and must be reached through titration from lower doses. This is fine if the general practitioner or practice pharmacist is prepared to put in the time and effort to monitor and titrate doses accordingly. In reality, however, we believe that most patients are not monitored and titrated appropriately. This leads us to recommend the use of agents which will give cost-effective lowering of cholesterol, in line with NSF targets, at the licensed starting dose. For this reason we recommend atorvastatin 10mg daily or simvastatin 20mg daily (giving prescribers the option of “class effect” or “evidence based”). Pravastatin is mentioned in our guidelines for its specific licence in stroke prevention, but we feel that it is a more expensive choice (as seen from Mr Petty’s table) and leaves no room for dose titration if the patient’s target cholesterol is not reached on the maximum dose of 40mg daily. Our final point involves the confusion surrounding NSF target cholesterol levels. Several companies claim that a certain percentage of patients will reach NSF target levels of 5mmol/L on the recommended starting dose of their drug. The NSF states, however, that the target level for total cholesterol is 5mmol/L or a 25 per cent reduction, whichever gives the greater reduction. Table 1 gives an indication of target cholesterol levels versus baseline levels.
It can be seen that the patient’s target total cholesterol is only 5.0mmol/L when their starting level is greater than 6.5mmol/L. In a patient with a baseline cholesterol of 5.7mmol/L, for example, the target level would be 4.3mmol/L. Care must be taken when interpreting trials which claim to give reductions in line with NSF target values.
Table 2 sets out the doses required of each statin to reach the NSF target as stated above, along with the cost per 28 days’ treatment to achieve this reduction. We hope that your readers will find this of use. Carl Booth Jeff Pearse |
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