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BMJ No 7122 Volume 315 Letters Saturday 13 December 1997
Use of statinsSee Editorial by Muldoon p 1554Adequacy of SMAC's statement should be judged by clinicians, not health economistsEditorFreemantle et al's editorial argues that the statement on the use of statins in coronary heart disease prepared by the Standing Medical Advisory Committee and issued recently by the NHS Executive is `simply inadequate.'(1,2) The adequacy or otherwise of advice depends on the context in which it was issued and whether it is appropriate for the purpose. The context was the dramatic increase in the prescribing of statins since the publication of two landmark randomised controlled trials (the 4S (Scandinavian simvastatin survival study)(3) and WOSCOPS (the west of Scotland coronary prevention study)(4)). Guidance issued by the European Society of Cardiology advised treating those of the population with a risk of coronary heart disease of 2% a year and over,(5) and others have advocated treating those with a risk of 1.5% and over. The annual cost to the NHS of treating all people with coronary heart disease and those with a 1.5% and over risk of developing symptoms would be of the order of £3.5bn. Most statins will be prescribed by general practitioners, and it was for them that authoritative but concise interim advice was primarily needed. The Standing Medical Advisory Committee convened a representative working party, including health economists. Its views were unanimous and, as the statement makes clear, were based on careful consideration of the 'clinical effectiveness, cost effectiveness and long term safety of statins.' The current information on statins is better than that available for most new drugs, although data on comparative cost effectiveness are incomplete. The priority for the NHS is to treat those who can derive appreciable benefit from statins but to obviate inappropriate prescribing. It was not assumed that all people in the three priority groups would necessarily be treated with a statin, but if the statement were followed then the resources available would be targeted most effectively. To be concise the statement could not be comprehensive or comprehensively referenced. Key references on clinical effectiveness were provided, but anyone wishing for further information was advised to contact a senior medical officer in the NHS Executive, which many, but not Freemantle et al, have done. The adequacy or otherwise of the Standing Medical Advisory Committee's statement should be judged not by health economists but by general practitioners and other clinicians. Its overall effectiveness should be judged against the rise in the drugs bill for statins, the appropriateness of future prescribing, and-possibly most importantly - the impact of statins on mortality from coronary heart disease. Peter Enoch
Chairman, Standing Medical
Advisory Committee
References
1 Freemantle N, Barbour R, Johnson R, Marchment M, Kennedy A.
The use of statins: a case of misleading priorities? BMJ
1997;315:826-8. (4 Oct.)
2 Winyard G. SMAC statement on use of statins.
London: Department of Health, 1997. (EL(97)41 HCD 750 IP
Aug 97.)
3 Scandinavia Simvastatin Study Group. Randomised trial of
cholesterol lowering in 4,444 patients with coronary heart disease: the
Scandinavian simvastatin survival study (4S). Lancet
1994;344:1383-9.
4 Shepherd J, Cobbe S M, Ford I, Isles CG, Lorimer A R, Macfarlane
P W, et al. for the West of Scotland Coronary Prevention Group
(WOSCOPS). Prevention of coronary heart disease with pravastatin in men
with hypercholesterolemia. N Engl J Med 1995;333:1301-7.
5 Pyorala K, de Backer G, Graham I, Poole-Wilson P, Wood D on
behalf of the Task Force of the European Society of Cardiology,
European Atherosclerosis Society, and European Society of Hypertension.
Prevention of coronary heart disease in clinical practice. Eur
Heart J 1994;15:1300-31.
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