Intended for healthcare professionals

Analysis And Comment Controversy

Should we lower cholesterol as much as possible?

BMJ 2006; 332 doi: (Published 01 June 2006) Cite this as: BMJ 2006;332:1330

statin side effects

Ravnskov and his colleagues (1) have to be congratulated on
their article stating that statins have more side effects than usually

They highlight selection bias and scientific mishandling of data
as possible sources for this misconception.

Selection Bias: The main statin studies exclude patients with
concomitant diseases ( mainly cancer and COPD). Additionally, some
studies like TNT (2) and HPS (3) exclude all patients who had side
effects with statin medication in the pre run. The reported low
number of patients with side effects therefore refers to those
patients only who did not have side effects in the first place and
were not excluded from the main trial.

Scientific Mishandling: PROSPER (4) showed a small but significant
increase in cancer incidence with Pravastatin treatment. The result
was buried in a makeshift meta analysis of unmatched trials.

Where does it leave us? What are the medical, ethical and legal
implications when we know that benefits from statin therapy for
the individual patient are small and fraught with problems. Should
UK General Practitioners receive ,quality payments’ by spending
approximately 4 – 6% of the total UK drug budget on drugs with growing
concerns about safety and tolerability. Could this money be better
spend on health promotion relating to life style changes ? (
Explanation for the Non-British readers : GPs in the UK receive so
called quality payments for reaching certain targets like putting
patients on statins etc.)

I seriously hope, that the article by Ravnskov et al. will start
a discussion of evidence.

1) Ravnskov U, Rosch PJ, Sutter MC, Houston MC. Should we lower
cholesterol as much as possible? BMJ 2006; 332:130-1332

2) LaRosa JC, Grundy SM, Waters DD, Shear S, Barter P, Fruchart J et al.
Intensive lipid lowering with atorvastatin in patients with stable
coronary disease. N Engl J Med 2005; 352: 1425 - 1435

3) Heart Protection Study Collaborative Group. MRC/BHF Heart Protection
Study of cholesterol lowering with Simvastatin in 20,536 high risk
individuals: a randomised placebo controlled trial. Lancet 2002; 360: 7-

4) Shepherd J, Blauw GJ, Murphy MB, Bollen EL, Buckley BM, Cobbe SM et al.
Pravastatin in elderly individuals at risk of vascular disease (PROSPER):
a randomized controlled trial. Lancet 2002 ; 360: 1623 - 30

Competing interests:
None declared

Competing interests: No competing interests

15 June 2006
Philipp Conradi
Otto-Dix-Ring 98 01219 Dresden, Germany