The National Institute for Health and Care Excellence (NICE) have issued a draft full guideline (over 270 pages in length) on lipid modification which, for patients with type 2 diabetes, would replace the current recommendations (REF 1). It recommends the UKPDS tool to assess CV risk and offer of ‘high-intensity statin treatment’ for primary prevention of CVD in people who have a 10% or greater 10-year risk. This is in contrast to the previous advice in NICE CG 66 which suggested a risk cut-off of 20% and use of simvastatin 40mg OD (now classed as ‘medium-intensity’).
The response of the Faculty of Public Health and the RCGPs was that there was the prospect of both over-treatment and over-medicalisation of hypercholesterolaemia. The former is supported by consistent data suggesting that development of type 2 diabetes is more common and control is worse in people receiving statins (2), whilst the latter might explain a report that statin-treated individuals consume more calories (presumably allowing for their medication to compensate) (3). The BMA view was that lowering the baseline risk for treatment would simply overwhelm already exhausted general practitioners (4). They were presumably not reassured by a publication which suggested that statin side-effects had been over-emphasised and were largely down to patients having been told about them (so, consultation times could be reduced by not having to mention muscle pains) (5). Apart from being difficult to believe, this paper was also unusual in that it was criticized by one of its own authors within days of publication (6).
Possibly of most interest, the Americans are changing their guidelines regarding statin therapy (7). For primary prevention (CVD risk >7.5% over 10 years) in type 2 diabetes and where the LDL-cholesterol is 1.8-5.0mmol/L, the recommendation is for introduction of a moderate-intensity statin. The big change, however, is that there is no longer a target to be achieved. This ‘fire-and-forget’ strategy could even reduce primary care workload.
Professor Steve Bain