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Practice Cases in primary care laboratory medicine

Testing pitfalls and summary of guidance in lipid management

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7558.83 (Published 06 July 2006) Cite this as: BMJ 2006;333:83

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Re: Statins should be first line in majority with hypertriglyceridaemia

I get very dismayed when I see such intricate dissections of the
minutia of cholesterol etc lowering, I see it as arguing about the colour
of the paint on a house whose foundations are totally insecure. There now
items in print entitled The Cholestrol Myths---- Con----Scam, and there is
also Thincs, the Institute of cholesterol skeptics, with many professional
members.

These have very well researched investigations into the validity of
much of the cholesterol saga, starting with Ancel Keys' very selective
collection of trial results on the association of saturated fats with
cholesterol level, apparently the seven countries which supported his
theory are countered in his trials by seven which gave precisely the
opposite result.

The early cholesterol lowering by such means as absorbtion in the
stomach often were counter productive, and the statin trials have been
clouded by the inclusion of those sufferring from the familial form, which
is not due to excess production of cholesterol, but due to a genetic
defect in ability to dispose of LDL cholesterol which then accumulates in
various parts of the body. It would appear that sometimes these have been
included (accidentally???) in control groups and exagerrated the statin
benefit.

So many £ millions have spent on trials and studies carried out with
insufficient discipline, or lateral thinking, for instance, the MRC/BHF
trial in the 1990s assembled a cohort of 60,000, reduced to 30,000 by
removing those with problems associated with reliability and clinic
access, but then the trial did not commence on Day 1, but there was a 2
month run in period in which the statin was given, but no note seems to
have been taken of the reasons for the quarter of those candidates who
declined to carry on into the recorded part of the trial which started on
the official Day 1. I suggest that many of them had the common side
effects related to statins and did not wish to continue further.

There was little difference in the death rate with higher cholesterol
levels, and the fewer number of deaths in the treatment group was the same
at all levels, leading to the amazing conclusion that levels should be
further reduced. A more logical and disinterested conclusion would be that
the lowering process was of benefit at all levels, but that the level
itself was not important. Which brings me to the subject of Homocysteine,
and by some freak, this is reduced along with cholesterol and the other
essentials, Q10 etc.

Prof McMully did some very informative research on homocysteine,
mortality from heart attack is very strongly associated with rise in
homocysteine level, the curve rises rapidly, almost following a square
law. This chance effect on homocysteine appears to be the main reason why
statins do save some lives, cholesterol lowering being mainly irrevelant.
McMully was "drummed out of the Brownies", probably for going against the
medical establishment of his day and the commercial interests of their
drug company sponsors, but his assertion that Homocysteine could be
countered by the use of cheap Folic acid, Vit B6 and B12 remains,(20p per
tablet, not patentable), and not a great money spinner like statins. The
almost universal addition of folic acid to flour and cereals makes it
difficult to perform trials as an untreated control group would be hard to
find.

It would be far more rewarding to investigate homocysteine than wreak
more havoc on a whole population with St Atins, which I consider to have
been beatified without the intervention of a Devil's Advocate.

Competing interests:
Statin damaged patient

Competing interests: No competing interests

12 August 2006
Raymond G Holder
Retired engineer
Nne BH9 3NF