Lipid Lowering in patients with High Risk of Cardiovascular Disease (Primary Prevention)

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1 Lipid Lowering in patients with High Risk of Cardiovascular Disease (Primary Prevention) Policy Statement: October 2010 This policy defines the decision made by NHS Wirral following an evidence review to assess lipid lowering treatments for patients with high risk of Cardiovascular Disease (CVD) i.e. Primary Prevention. NHS Wirral has agreed that: Treatment for the primary prevention of cardiovascular disease should be initiated with simvastatin 40 mg. If there are potential drug interactions, or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin may be chosen. What this means for patients is:- Your GP should only prescribe simvastatin or pravastatin on NHS prescription because the evidence does not support the use of other statins in primary prevention. You can contact us on or freephone or at haveyoursay@wirral.nhs.uk if you have any concerns. Version 1.1 Approved by: Professional Executive Committee Date Approved: Date of implementation: October 2010 Produced by: Medicines Management Team Review Date: Earliest of NICE publication or other national guidance or two years from issue. : Lipid Lowering in patients with High Risk of CVD (Primary Prevention)

2 Further information about this document: Document name Category of Document in The Policy Schedule Author(s) Contact(s) for further information about this document This document should be read in conjunction with Lipid Lowering in patients with High Risk of Cardiovascular Disease (Primary Prevention) Commissioning Policy Medicines Management Team Telephone: Wirral Medicines Guide Wirral guidelines on Lipid Lowering in patients with high risk of CVD (primary prevention) Published by NHS Wirral Old Market House Hamilton Street Birkenhead CH41 5AL If you have any concerns please contact us on Copies of this document are available from Version Control: Telephone: Freephone: Website: Hard copies from the Medicines Management Team Version History: Version Number Reviewing Committee / Officer Date 1.0 Primary Care Prescribing Committee Professional Executive Committee The following terms are used in this document BNF The BNF provides prescribers, pharmacists and other health care professionals e.g. nurses with up to date information about medicines prescribed in the UK : Lipid Lowering in patients with High Risk of CVD (Primary Prevention)

3 : Lipid Lowering in patients with High Risk of CVD (Primary Prevention)

4 Lipid Lowering in patients with High Risk of CVD (Primary Prevention) 1. BACKGROUND 1.1 The purpose of this policy is to outline the decision taken by NHS Wirral regarding the prescribing of lipid lowering agents (statins) for primary prevention of CVD. This policy applies to all prescribers, both medical and nonmedical. 1.2 Statin therapy is recommended as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD. This level of CVD risk should be estimated using an appropriate risk calculator, or by clinical assessment for people for whom an appropriate risk calculator is not available. 1.3 NICE issued guidance on the use of statins (Clinical Guideline 67) in May 2008 (reissued March 2010). This guidance recommends that when a decision has been made to prescribe a statin.that treatment for the primary prevention of CVD should be initiated with simvastatin 40 mg. If there are potential drug interactions, or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin may be chosen. 1.4 Before offering lipid modification therapy for primary prevention, all other modifiable CVD risk factors should be considered and their management optimised if possible. 2. EVIDENCE 2.1 There is robust clinical evidence that statins reduce the risk of cardiovascular events in patients up to the age of 80. They also bring about a 20% reduction in total cholesterol and a 28% reduction in low-density lipoprotein (LDL) cholesterol. 2.2 NICE considered the clinical evidence from meta-analyses and large randomised controlled clinical trials of statins for primary prevention in its Full Guideline for lipid modification. 2.3 Absolute CVD risk is estimated by using the CV risk prediction charts in the British National Formulary (BNF) or an appropriate computer programme. A formal assessment must be done treatment based on a lipid level alone is not appropriate. Lipid levels alone are a poor predictor of risk. 2.4 PCTs using high levels of generic statins have been as successful in achieving QoF targets as those with higher use of atorvastatin, rosuvastatin or fluvastatin, supporting the use of the less expensive, generic statins 2. : Lipid Lowering in patients with High Risk of CVD (Primary Prevention)

5 3. CONCLUSIONS 3.1 Treating patients with a less than 20% 10-year CVD risk is NOT recommended. Patients at lower risk require lifestyle advice, including smoking cessation support. Follow-up may be appropriate. 3.2 No targets for total or LDL-cholesterol are recommended. Once a patient has been started on a statin for primary prevention, repeat lipid measurement is unnecessary because doses do not need to be increased to reach targets. Clinical judgement and patient preference should guide the review of drug therapy and whether to review the lipid profile. 3.3 Simvastatin is the recommended statin. The recommended dose is 40 mg daily, taken in the evening for maximal effect. If not tolerated try 20mg daily, or alternatively, switch to pravastatin 40mg daily 3.4 If statins are not tolerated, fibrates may be considered 3.5 Ezetimibe (Ezetrol) is not licensed for primary prevention of cardiovascular disease, although it should be considered in those with primary hypercholesterolaemia. 3.6 It is recognised that using generic simvastatin is the best use of NHS resources in order to provide value for money. A consequence of non compliance with this policy could be that other services may suffer if expensive statins continue to be prescribed unnecessarily. 4. RESPONSIBILITY FOR IMPLEMENTATION 4.1 Responsibility for implementation lies with GP practices and Practice Based Commissioning clusters. 5. ROUTE FOR POLICY DEVELOPMENT AND RATIFICATION 5.1 All prescribing policies are underpinned by detailed clinical evidence reviews. Draft policies are subject to consultation at local clinical meetings with Medical Directors, GPs and pharmacists. The final policies are ratified at the Professional Executive Committee and published on the PCT website. 6. REFERENCES 1 NICE. Lipid Modification. Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. CG67. March Petty D, Lloyd D; Can cheap generic statins achieve national cholesterol lowering targets? J Health Serv Res Policy Apr;13(2): : Lipid Lowering in patients with High Risk of CVD (Primary Prevention)