Editor—Wallace et al highlight important issues on managing so called hyperlipidaemia.1 The timing of the statin dose is irrelevant, with current policy and practice not designed to deliver the clinical outcomes seen in recent drug trials.2 They studied suboptimal doses, which is common; data from the West Midlands show that 36% of patients are prescribed simvastatin 10 mg or pravastatin 10 mg (table).
Table 1.
Proportions of pravastatin and simvastatin prescribed by general practitioners in West Midlands between July 2002 and June 2003
| Strength (mg) | Pravastatin (6 697 175 items) | Simvastatin (33 656 378 items) |
|---|---|---|
| 10 | 28 | 38 |
| 20 | 35 | 37 |
| 40 | 37 | 24 |
| 80 | — | 1 |
The Prescription Pricing Authority gave permission to analyse and show these data.
The national service framework for coronary heart disease set a target that statin treatment should aim to lower cholesterol below 5.0 mmol/l or to reduce total serum cholesterol by 20-25%, whichever would result in the lowest concentration.3 The quality and outcome framework of the new general practitioners' contract4 will reward according to the proportion of patients with vascular disease, or diabetes, with total cholesterol concentrations below 5 mmol/l.
The heart protection study shows that many people derive benefit irrespective of their starting cholesterol concentration.5 Thus the policy is not now evidence based; people may be inadequately treated if their “starting” cholesterol is less than 5 mmol/l. Also some may be aggressively treated, with drugs such as rosuvastatin or ezitimibe, where there are no clinical outcome data, to achieve cholesterol concentrations below 5 mmol/l. This clearly suits the drug industry.
We should rethink national policy; people with significant risk should receive statin at a dose used in recent trials2 (simvastatin 40 mg daily, or pravastatin 40 mg daily). These trials did not chase their target. Giving the dose in the evening might help but a proper dose should be used. The general practitioner's quality payment could then be for the proportion of appropriate people receiving these evidence based doses.
Competing interests: None declared.
References
- 1.Wallace A, Chinn D, Rubin G. Taking simvastatin in the morning compared with in the evening: randomised controlled trial. BMJ 2003;327: 788. (4 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Durrington P. Dyslipidaemia. Lancet 2003;362: 717-31. [DOI] [PubMed] [Google Scholar]
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- 4.British Medical Association. New GMS contract. Investing in general practice. London: BMA, 2003.
- 5.Heart Protection Study Collaborative Group. MRC/BHF heart protection study of cholesterol lowering with simvastatin in 20 536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002;360: 7-22.12114036 [Google Scholar]