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Rapid Responses: Rapid Responses published:
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High discontinuation rates with statin drugs
- Leon A Simons (27 October 2000)
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Measures required for standard application of guidelines
- Matt Hawker (10 November 2000)
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"Statins: Underused by those who . . .
- J I Logan (29 November 2000)
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Leon A Simons, Assoc Professor of Medicine University of NSW
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Hulley et al in their editorial (BMJ October 21) stress that statins are underused in patient populations with prior coronary disease and possibly in some groups without prior disease but still at high coronary risk! While barriers may remain to the implementation of this treatment on a necessarily wider scale, I would draw attention to the oft-forgotten problem of discontinuation of treatment once started. In a letter in this week's journal (October 28th), we have examined retention rates on lipid-lowering drugs across Australia. Around 30% of 32,384 patients newly prescribed these drugs in April 1999 (92% receiving statin drugs) had discontinued treatment within 6-7 months, indicating wasted expenditure and effort and a lost opportunity for proven heart disease prevention. |
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Matt Hawker, Senior House Officer in Accident and Emergency City Hospital NHS Trust, Birmingham
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EDITOR - The editorial on underuse of statins by Hulley et al concords with my own audit. This retrospectively examined the use of statins in the secondary prevention of coronary disease in 38 patients at a large district general hospital in the South of England. Current practice during the study period was based on the Standing Medical Advisory Committee guidelines on statin use (1997). Eighty-nine percent of patients presenting with an ischaemic event had a cholesterol measurement within 1 year. Twenty-one percent of post-infarction patients did not receive a statin when indicated; this figure rose to 67% in patients presenting with non-infarct angina. Only 39% of patients had their cholesterol re-measured during the 1 year study period to check response to statin therapy. Hulley et al call for physicians to do a better job of following guidelines. At a local level attempts were made to remedy poor cholesterol management by presentation of the results at the Journal Club and through guidelines inserted into the hospital's clinical handbook. The National Service Framework of Coronary Heart Disease attempts to standardise NHS care throughout. Clearly the simple existence of standard guidelines is inadequate - measures are required to ensure their standard application. Hulley S B, Grady D, Browner W S. Statins: Underused by those who would benefit. BMJ 2000;321:971-2. (21 October.) Standing Medical Advisory Committee on use of statins. NHS Executive. London: Department of Health, May 1997. |
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J I Logan
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EDITOR - It is surely a nonsense for Hulley et al to state in their editorial of 21 October on the use of statins that "There is no longer any doubt that treatment benefits those who are at substantial coronary risk." They claim that the meta-analysis of randomised trials of lipid lowering drugs published in the same issue of the BMJ supports their position but the meta-analysis shows that 239 persons must be treated to prevent 1 death from coronary heart disease, and that 479 persons must be treated to prevent 1 death from all causes. It may be true that the reduction in coronary heart disease mortality in the study population is statistically significant but it is quite clear that the vast majority of individual patients derive no benefit whatsoever from treatment with statins. Is it not time to agree that in addition to tests for statistical significance, results should only be accepted as relevant if they also have clinical significance? This could best be defined as the number of persons who would need to be treated for a fixed period of time (perhaps five years) to prevent one significant event (such as death). The actual number of persons would have to be agreed and it would be reasonable to look away from the drug companies and researchers and towards clinicians and patients to determine what this number should be. Even if it were as low as five, this would still mean that 80% of those treated would not benefit. JI Logan
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