Statins, saving lives, and shibboleths
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39163.563519.55 (Published 26 April 2007) Cite this as: BMJ 2007;334:902
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Preventive medicine based on using drugs to treat risk factors is
inane. Many risk factors might be more appropriately referred to as "risk
markers", since they are merely statistical associations rather than
causative agencies. Cholesterol is a good example; with the oft cited
"for every 1% fall in cholesterol there will be a 2% reduction in coronary
heart disease. This is another deceptive shibboleth, ("a common saying or
belief with little current meaning or truth") since what this really
refers to is a reduction in relative risk, rather than absolute risk,
which is quite different.
Statin manufacturers have capitalized on this in their TV and media
blitz in the United States because of the power of direct to consumer
advertising. For example, you could be told of a statin that is safe and
will significantly "reduce the risk" of having a heart attack if taken
every day for the next five years. A study is cited showing that over
five years, patients on this statin had 34% fewer heart attacks than
controls on a placebo, which is correct, since this is relative risk
reduction. What you are not told is that 2.7% of patients on the drug had
a heart attack compared to 4.1% on placebos, so that the absolute risk
reduction is only 1.4%. Also not revealed is that if this statin is taken
by seventy-one people every day for five years, it will prevent one person
from having a heart attack - but it is not known if that person will be
you. In point of fact, you will never see a statin ad claiming that the
drug actually reduces heart attacks. In many instances, a disclaimer is
mandated stating that it has NOT been shown to prevent heart attacks or
heart disease, although this is usually in fine print.
It is quite clear that the cardioprotective effects of statins are
not related to lowering cholesterol or other lipids. (1) Thus, the current
goal of lowering LDL to an arbitrary value that is often difficult to
achieve insures increasingly higher doses for longer periods of time. (2)
This means more money for drug companies but it also insures a higher
incidence of adverse side effects, many of which have been ignored or
suppressed. (3,4) As Professor Blackman implies, what we call a health
care system is a mighty double misnomer. What we really have is a
sickness cure system. Similarly, health insurance primarily provides
compensation when we are sick, rather than health enhancement.
What is sorely needed is to make prevention a priority by emphasizing
the importance of regular exercise, proper nutrition, adequate sleep,
reducing stress and other lifestyle changes shown to reduce coronary
disease. The public would profit much more from this than from putting
statins in the drinking water, especially since statins have not been
shown to reduce coronary disease in men over 65 or women of any age.
Unfortunately, a shift to this preventive approach is not likely to happen
because of powerful pharmaceutical companies who will do anything to
perpetuate and preserve their prodigious profits.
1. Rosch, PJ. Guidelines for Diagnosis and Treatment of High
Cholesterol. JAMA. 2001;286:2400-2402
2. Rosch PJ. Determining optimal statin dosage. Mayo Clin Proc. 2003
Mar;78(3):379, 381
3. Rosch PJ. Peripheral neuropathy. Lancet 2004;364:1663
4. Graveline D. Statin Drugs – Side Effects and The Misguided War on
Cholesterol. 2006 published by www.spacedoc.net
Competing interests:
None declared
Competing interests: No competing interests
Professor Blackman discusses the benefits of local councils taking
responsibility for health. In theory this should be a step forward, and
indeed was part of previous Government policies. But in practice this does
not always work out.
As an ophthalmologist wanting to reduce diabetic retinopathy, I see
the most effective way to reduce the increase in type 2 diabetes is by
encouraging exercise, and there is no better way to encourage walking and
cycling.
I therefore sit with the two public health physicians on our
Council’s Children’s Health and Obesity Task Force, and this group has
asked for slower speeds across the city and cycling training. These are
probably the most effective measures of making a cycling and walking safer
and more popular, and are part of European Union policy.
But these and all other large scale slow speed or pro-cycling
measures have been rejected by other committees in the Council. The
Transportation Department sees its role as preventing traffic jams and
accidents and helping industry (and accident rates have dropped at the
same time as cycling and walking rates have fallen). And Government
policies support this…the last Transport plan implemented included many
‘Red Routes’, which increase speed of traffic flow, and certainly do not
aid cycling and walking.
The planning department approves large hypermarkets with masses of
car parking and which increase traffic, and large entertainment complexes
which in practice cannot be reached by walking, whilst allowing many
smaller green spaces in the city which are used for improvised sport to be
developed into housing. These changes are occurring in all UK cities,
basically opposite to planning decisions in cycling cities such as those
in Holland and Denmark.
Our Council leader has adopted Government policy, and if the policy
will ever change it will be a slow job. And the potential captains of the
liner, whilst talking ‘green’, have rejected proposals such as city wide
cycling networks (personal communications).
Local and national leaders have to take public health and environmental
issues a lot more seriously if Councils are to act effectively.
Competing interests:
None declared
Competing interests: No competing interests
Re: Statins, Statistics And Saving Lives
The role of preventive medicine, such as in the use of statins, does
not get to the heart of the matter. An old senior engineer, for whom I
worked, once remarked of complex electromechanical systems " Put it into
the state which the designer intended, and it will work" Now we may not
know what our designer intended, but we do know what things are necessary
for healthy living, vitamins, all the necessary nutrients, etc, and we
know what levels of these substances are found in a healthy body, if we
look far enough into current knowledge. It is routine to measure blood
chemistry to measure iron, potassium, sodium, calcium etc levels and
vitamin levels and those of other body necessities.
Some of the more recent discoveries are less often examined, or the
need to examine them is not recognised, for example Coenzyme Q10,
Carnitine, homocysteine and the B vitamins etc necessary to prevent its
production. Making sure that all these substances, and others in similar
need, are available in sufficient quantity, is surely the first step to
getting the body into full working order. The use of drugs to alter that
state to something less than optimum is only counter productive in the
longer term, probably because an unforeseen side effect has not been
imagined or properly thought through.
The treatment of hypertension is a case in point. I believe that a
lot of this effect is due to CoQ10 reduction with age, and the strength of
the heart pumping action is impaired. But Beta blockers are known to
affect CoQ10 production just as statins do, and the heart problem suffers
more. Calcium antagonists alter muscle action, and have also been found to
worsen statin side effects, supplementary CoQ10 often makes their use
unnecessary. We are bound up in a system where the first approach is to
reach for the "system modifier drug catalogue", instead of looking for
what is that particular patient's personal deficiency, and bringing it
back into the normal range.
If more attention were to be paid to this approach, the many statin
side effects which now go unexplained by the doctors in charge of their
cases, because CoQ10, carnitine, and similar damage sites would be
recognised, and the cry "statins have very few side effects" would be
shown to be more than untrue, and some global recognition of the problem
would have to be made.
Competing interests:
Statin damaged patient
Competing interests: No competing interests