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Letters to the Editor
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Statins
Whether to initiate therapy is a simple decision
From Mr R. J. S. Trotter, MRPharmS
After reading J. W.
Clitherow’s discussion of the management of
his cholesterol (PJ, 10 March, p282), I am compelled to respond to his
criticism of the National Institute for Health and Clinical Excellence
and its guidelines. I thank him for the opportunity to explicate the decision
whether to initiate statin therapy since people often complicate what is,
in essence, a simple decision.
First it is necessary to establish whether a person is at high risk of
having a cardiovascular (CV) event, A person is considered such if they
have prediagnosed cardiovascular disease (CVD) or have a 10-year CVD risk
score of 20 per cent or greater. CVD risk can be calculated using the charts
at the back of the BNF. (The serum total to HDL cholesterol ratio is only
one component of this calculation.)
If a person is at high risk of having a CV event, his or her cholesterol
should be examined and a statin should be offered if it is above “target”.
(The Joint British Societies’ Guidelines 2005 [JBS-2] additionally
recommend a statin is offered to other groups of people, including those
with diabetes mellitus or with a serum total to HDL cholesterol ratio exceeding
6, irrespective of CV risk score or cardiac history. These guidelines also
recommend that people with acute atherosclerotic disease are offered a
statin regardless of the initial measured serum cholesterol.)
Mr Clitherow correctly reminds us that guidelines are just that: intended
to guide prescribers not to override their clinical judgement. His assertion,
however, that NICE has made its own recommendations on the choice and dose
of statin is erroneous. NICE actually recommends a statin with a low acquisition
cost for people at high risk of having a CV event and advises that the
decision whether to initiate statin therapy should be made after an informed
discussion. Patient choice is now driving many agendas and I suggest that
we all exercise those rights.
It is likely that his GP referred to local cholesterol management guidelines,
if they recommend simvastatin at a dose of 40mg each night initially for
most people; this is an extremely safe, effective and cost effective strategy.
Mr Clitherow may just have been unlucky.
We must remember that the evidence that statins and cholesterol lowering
reduce CVD morbidity and mortality is compelling. I understand NICE is
currently considering whether the NHS can afford to update the thresholds
and targets from “5 and 3” to “4 and 2” for total
cholesterol and LDL cholesterol, respectively. I ask can we afford not
to?
Robert Trotter
Cardiovascular Lead
Medicines Management Team
Liverpool Primary Care Trust |
The
Pharmaceutical Journal