Adequacy of SMAC's statement should be judged by clinicians, not health economists

See editorial by Muldoon

Editor—Freemantle 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,5 and others have advocated treating those with a risk of ≥=1.5%. The annual cost to the NHS of treating all people with coronary heart disease and those with a ≥=1.5% 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 …