The CASE for fire and forget

I write with reference to the editorial by Donner-Banzhoff and Sönnichsen.¹ Four factors make the CASE for Shepherd’s original proposal to move the prescription of statin on to the same footing that aspirin now occupies.²

• Cost—A diminishing returns dose-response curve exists, whereby the initial 10 mg of simvastatin produces 75% of the maximum response, and each dose increment produces a reducing incremental gain, at increasing cost per unit gain. For example, since 10 mg of atorvastatin produces half the cholesterol lowering achieved by 80 mg atorvastatin, and drugpricing is effectively linear, then offering eight people 10 mg of atorvastatin is four times as effective as offering one person 80 mg. Atorvastatin is 20 times more costly than simvastatin, but only twice as potent, dose for dose

• Acceptability—Avoidance of unnecessary repeated cholesterol tests and clinic visits is welcomed by patients, doctors, and health accountants

• Safety—The risk of side effects increases with dosage

• Effectiveness—All patients at cardiovascular risk benefit from statin treatment, regardless of their initial cholesterol level.

The benefits to the nation of generically priced simvastatin are 20 times that of the patent price atorvastatin. The higher the cardiovascular risk the greater the gain, regardless of cholesterol. A threshold of risk exists (currently a 10 year cardiovascular risk >20%), above which the balance of harm is outweighed by the benefit of 10 mg simvastatin, providing the greatest good to the greatest number, at an affordable cost to the nation.

Who needs polypills and polyclinics? Your local pharmacist now offers a simvastatin and an aspirin a day, to keep the doctor away.