Getting nasty with NICE
This month's release from a newly updated National Institute for Health and Care Excellence (NICE) website included the much debated Lipid modification clinical guideline. The draft of this guidance prompted a letter whose signatories included Richard Thompson, president of the Royal College of Physicians, and Clare Gerada. They warned of the risks of 'medicalising' five million healthy people on the basis of drug company trials. There were also media reports that a majority of the guideline panel had ties to drug companies producing statins. The public was outraged and indignant. Further media coverage highlighted adverse effects of statins. The public was defiant. It would not be poisoned by unscrupulous doctors.
However, there is (inevitably) another compelling way of viewing this argument. The guideline recommends that doctors should intervene more intensively by implementing primary prevention efforts in people with a 10% risk of developing cardiovascular disease over the next 10 years. The previous iteration (2008) advised intervention where there was a 20% risk of cardiovascular events. Lowering the threshold for intervention will potentially bring a further 4.5 million people into our surgeries. Doctors are already barely coping and this prospect is scary. However, we should not forget that heart disease remains the largest cause of morbidity and mortality in the UK. It is an incredibly important problem - is greater intervention really to be discouraged?
Of course our first option will be changes in lifestyle, but we may also consider prescribing statins. It has been estimated that perhaps two million to 2.5 million people might be given them. The expected outcome, if patients comply, would be to save two deaths, four strokes, and seven non-fatal myocardial infarctions in every 1,000 people over three years. If this estimate is right, 4,000 lives might be saved. These figures represent a number needed to treat of 77. That is, 77 people would need to take the pills for three years for one of the events above to be avoided. It should be noted that this is significantly lower than with existing advice regarding the treatment of high blood pressure, which has a number needed to treat of 104. Hypertension is largely symptomless, as is hypercholesterolaemia. Both are important factors in the development of cardiovascular disease. Why treat one and not the other?
Away from the media glare, a conscientious GP will do what GPs always do: weigh up the risks and benefits for an individual patient and have an informed discussion with them before coming to a (joint) decision.
To help you have evidence-based discussions with your patients, this month we have updated our information in line with the latest guidance. Our resources on lipid/cholesterol management are currently being reviewed in line with the new guidance and will be released shortly. New resources include a selection of diet information sheets suitable for conditions such as gout, IBS and anaemia.