Three Chequers Medical Practice
72 Endless Street Salisbury
SP1 3UH
T: 01722 336441
www.3chequers.co.uk

Dear Patient,

We have contacted you because you may benefit from taking a cholesterol-lowering medication called a “statin”.

Statins are a group of medications which are primarily used to reduce the risk of heart and blood vessel disease. This mainly refers to stroke disease, heart attacks and angina, but includes other forms of vascular disease such as kidney disease and peripheral vascular disease. They can be prescribed to reduce the risk of developing this (primary prevention) or to reduce worsening of established disease or further episodes (secondary prevention). In this instance, we would mainly be using statins for primary prevention. People who have already developed this sort of problem, or have diabetes, ideally should already be taking statins.

The medication works by improving cholesterol levels but also by stabilising fatty plaques in your blood vessels, making them less likely to burst and cause blockages in blood vessels, in turn cutting off blood supply and causing disease. 

The National Institute of Clinical Medicine (NICE) have typically recommended that patients with an estimated 10-year risk of over 20% should be recommended statin treatment. More recently they have advised that the medication can be offered at a 10% cut off. NICE provide evidence-based guidelines to the NHS. A 20% risk suggests 2 in 10 people will have a heart attack or stroke over the next 10 years.

Our records indicate your estimated cardiovascular risk (risk of a heart attack or stroke) in the next 10 years is at or over this threshold. This figure is a computerised estimate based off your personal demographics (age, sex) and other risk factors (smoking, blood pressure, other medical problems such as diabetes). Attached below is a link to the NICE patient decision aid. Your estimated cardiovascular risk is over 20, and the majority of people have a risk between 20-30%.

Statins   NICE Statin Patient Decision Guide 

There is no obligation to have a statin prescribed. It is not an urgent decision, and it is unlikely that delaying this by weeks or even months would make a significant difference to your immediate risk. Statins work to reduce risk of vascular disease over the course of years. However, it may be that you would consider this and if so, please consider reading the following information:

FAQs:
1. What does taking a statin involve?
You will take 1 tablet once a day, usually before bed (as cholesterol is mostly made at night). Treatment with a statin is normally long term, although if you do not tolerate the medication or change your mind you can stop taking it. The first line statin is typically Atorvastatin, although there are several others such as Simvastatin or Rosuvastatin.

2. What difference will taking a statin make to my risk of ischaemic heart disease and stroke?
At an estimated 20% 10 year risk, 20 people out of 100 would be expected to develop cardiovascular or stroke disease. If all of these people were to take a statin over this period, 7 of those 20 people would be expected to be saved from a stroke or cardiovascular disease. At 30% risk, 11 people of the 30 people would be predicted to be saved from developing cardiovascular disease or stroke. As your estimated risk increased, the relatively benefit would also increase. The above ‘NICE Statin Patient Decision Guide’ explains this in more detail for different estimated risk groups.

3. What are the risks of getting muscle pain while taking a statin?
Many people who take statins experience muscle pain from time to time but in clinical trials about the same proportion of people overall had muscle pain at some point, whether they took dummy tablets or statins. The UK independent safety regulator for medicines estimates that in every 1000 people who take statins, over a year on average 2 of them will experience mild muscle pain. Muscle pain is most likely in the first 3 months of treatment. Rarely, some people taking statins have developed abnormal muscle breakdown, which can lead to kidney problems and be life-threatening. The UK independent safety regulator for medicines estimates that for every 100,000 people who take statins, over a year about 1 or 2 of them on average will experience this type of muscle damage. Some people are more likely to develop muscle problems as a result of taking a statin, so before you start treatment your healthcare professional will ask you about factors that make it more likely that you might get these problems.    

4. What are the risks of developing diabetes while taking a statin?
Some people who take statins develop diabetes, but some people of a similar age and lifestyle who don’t take statins also develop diabetes. When atorvastatin 80 mg daily (the highest dose) was compared with a dummy tablet in a clinical trial, over an average of 5 years about 9 people in every 100 who took atorvastatin developed diabetes (and 91 in 100 did not), and about 6 people in every 100 who took dummy tablets developed diabetes (and 94 in 100 did not). There is no good evidence to say what the risk of diabetes would be over a longer time period and it is possible that it would be less with lower doses of atorvastatin. Some people are at greater risk of developing diabetes whether or not they take a statin. This includes people whose blood sugar is higher than normal, or who are overweight or obese.  

5. What are the other common side effects of statins?
Every effective medication has a risk of side effects, most of which are minor and/or self-limiting. This is true of commonly used medications such as paracetamol or hayfever tablets, and also true of statins. Most people tolerate the medication well without any issues.

The following side effects can affect up to 1 in 10 people who take Atorvastatin (the statin usually recommended): · inflammation of the nasal passages, pain in the throat, nosebleed · allergic reactions · headache · nausea, constipation, wind, indigestion, diarrhoea. Other side effects have been reported with statins but are less common.  https://www.nhs.uk/conditions/statins/side-effects/

If you believe you are having troublesome side effects of the medication, it is reasonable to stop taking the medication for a short period and see if the symptoms resolve. If they do, it is possible this was a side effect of the statin, although it is possible it was a co-incidence. Sometimes we will advise re-trying the medication to see if the possible side effect return. We would advise discussing any persistent or significant issues with a GP or clinician. It may be that an alternative medication or a lower dose would be a good option.

6. Will I need any regular blood tests?
We would typically re-check blood tests prior to initiating a statin and then around 2-3 months and 12 months after starting a statin. This is because a very small percentage of people can develop abnormalities of liver enzymes with statin treatment. We would also re-check the cholesterol levels at this point. Many patients who have had blood tests recently would not need a further blood test prior to starting a statin. We would not be able to prescribe a statin to patients with liver disease or those who are currently pregnant/breastfeeding.

7. Will I have to change what I eat and drink?
Whether you take a statin or not, you should try to eat a healthy diet. If you decide to take atorvastatin you should not drink more than 1 or 2 small glasses of grapefruit juice per day because large quantities can change the effects of atorvastatin.  

8. Will the statin interact with other medicines I take?
Statins are very commonly prescribed alongside most other medications, although there are some possible interactions. These include amiodarone, macrolide antibiotics (clarithromycin/erythromycin), some HIV medications (e.g. tipranavir, telaprevir) and some oral antifungal medications. A clinician will have access to your records and drug history prior to prescribing. A full list of all possible interactions, minor and major, are included here: https://bnf.nice.org.uk/interactions/atorvastatin/

After receiving this information, if you would like to start a statin medication please do get in touch with the surgery in the usual way or contact three.chequers@nhs.net. If you do not want to consider statins, to avoid duplication, it would still be helpful to hear from you via email/SMS so we can ensure this is documented on your notes.

We will then need to review your medical notes and ensure the medication is suitable for you before arranging a prescription, which will require a bit of time, so we do appreciate your patience. This is to double check blood tests, medication interactions, allergy status etc.

We may need to ensure you have had the relevant blood tests done before this prescription is done, which may require contacting you to arrange these. We will need to ensure you are on our recall system to have a further blood test in 2-3 months. We would be very grateful if, when receiving an initial prescription, you make a note in your diary to arrange a blood test in 3 months. This is a back-up safety precaution in the event our recall system does not work (e.g. you move house without updating your contact details or move GP surgery, or similar). This blood test would be for cholesterol and liver function tests.

There is no obligation to start medication. If you have an upcoming review, you may decide to discuss this with the Clinician at this time. You can contact the surgery to discuss this with a Clinician in the usual way if you have further queries or concerns.

If we do not hear from you, we will make the assumption for now that you do not wish to consider statins medication at this time.