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BMJ No 7122 Volume 315

Letters Saturday 13 December 1997

Use of statins

See Editorial by Muldoon p1554

In New Zealand, subsidy of statins is limited to particular groups of patients

Editor
The issues brought forward in the editorial by Freemantle et al are not limited to Britain.(1) Countries and doctors all over the world are struggling with the question of which patients should be treated with statins.

In New Zealand the government funding agency (the Pharmaceutical Management Agency (PHARMAC)) made a decision on treatment with statins that was based partly on clinical advice from an expert subcommittee and partly on a cost utility analysis. This decision limits subsidy of statins to the following groups:

  • patients with clinically proved ischaemic heart disease with a total cholesterol concentration of >6.0 mmol/l;
  • patients who have had coronary artery bypass grafting with a total cholesterol concentration of >5.5 mmol/l;
  • patients with a family history of ischaemic heart disease, with a proved ischaemic stroke, with a history of ischaemic attack, with a history of intermittent claudication, or with established diabetic nephropathy who have a total cholesterol concentration of >6.0 mmol/l;
  • all other patients with a total cholesterol concentration of >9.0 mmol/l.

    As a result of a recent negotiated reduction in cost, all available statins in New Zealand (fluvastatin, pravastatin, and simvastatin) are now subsidised at the same daily cost (NZ$1.05; 42p); the cost per quality adjusted life year is estimated to be NZ$10,000 (£4150) or less for treatment of the designated groups. Under the previous costings, the cost per quality adjusted life year even for patients with greatest benefit (those with clinically proved ischaemic heart disease with a total cholesterol concentration of >7.0 mmol/l) was NZ$28,000 (£11,600).

    Our analysis suggests that for patients requiring primary prevention who are at very high risk, such as those in WOSCOPS (west of Scotland coronary prevention study), the cost per quality adjusted life year is around NZ$15,000 (£6,200) at the new subsidy. It would have been around NZ$60,000 (£24,900) at the previous subsidy. Clearly, the price of statins and the baseline risk of the patient have an important effect on the cost effectiveness of the programme.

    We agree with Freemantle et al that, at the present time, statins should only be used to treat patients judged to be at risk similar to or greater than that of the patients in the 4S trial (Scandinavian simvastatin survival study). An international discussion on how to make such decisions based on solid cost effectiveness data is needed. This would facilitate the process for individual countries in deciding what they can afford.

    Win Bennett Medical director
    Wayne McNee Therapeutic group manager
    Scott Metcalfe Public health physician
    PHARMAC,
    PO Box 20-253,
    Wellington,
    New Zealand

    James M Wright Associate professor of clinical pharmacology
    University of British Columbia,
    Vancouver,
    BC,
    Canada

    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 October.)

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