A few times on this site I have written about the writings of Dr Des Spence – columnist in the British Medical Journal and practising doctor based in Scotland, UK. Regularly, Dr Spence uses his column to expresses doubt about the ‘wisdom’ of conventional medical practice, and quite frequently takes a swipe at what he regards as ‘bad medicine’. Quite recently, for instance, Dr Spence lamented the pharmaceuticalised management of diabetes, which I wrote about here.
Recently, Dr Spence’s chosen subject of the week was cholesterol-reducing statin drugs [1]. To put this context, my experience tells me that the majority of general practitioners here in the UK have considerable appetite for these drugs, and generally don’t hesitate to whip out the prescription pad when the advice to ‘eat a low-fat diet and take exercise’ fails to ‘control’ cholesterol levels sufficiently. Recent times have seen some suggest that statins should be more widely prescribed, including to the middle-aged. Dr Spence, though, questions whether his is good medicine.
Dr Spence draws our attention to the fact that our management of cardiovascular disease is based on risk factors such as cholesterol, blood pressure and blood sugar levels, but also points out that there is a view that that there is no ‘normal’ level of cholesterol in the bloodstream.
There has been a gradual downward drift of what is regarded as an acceptable cholesterol level and some attempt to popularise the idea that, when it comes to cholesterol, the ‘lower is better’. But we know, for example, that pretty much everything may be bad in excess, but the body may suffer if levels are too low too. This goes for blood sugar, blood pressure, body temperature, sodium levels and a myriad other things.
Now, one might argue that cholesterol is just a poison, of course, like arsenic and cyanide. But then why would it be a constituent in every cell in the body, and a critical component of other things including key hormones and vitamin D? It should perhaps be borne in mind that low levels of cholesterol are associated with enhanced risk of death, including from cancer.
The thrust of Dr Spence’s issue with statins concerns their effectiveness in low risk individuals. He states (and he’s right, I think), that the effects of statins need to quantified. What he’s alluding to here is the fact that while statins are often said to reduce the risk of, say, heart attack by about a third, this only becomes meaningful when someone’s risk of having such an event is high.
A good way to gauge effectiveness is through a measurement known as the ‘number needed to treat’. So, for example, we might ask how many people would need to be treated with statins for a year to prevent a cardiovascular event such a heart attack or stroke. Dr Spence informs us that the figure for low risk individuals over the age of 60 is 460. And the number need to treat to prevent one cardiovascular death comes out at somewhere between 1,250 and 5,000. Trust me when I tell you that when these sort of figures are presented to individuals, and the possible side effects explained too, most people decide they won’t bother.
Dr Spence ends on a low note:
But scepticism is futile. Guidelines will be issued to expand statin use, and these orders dutifully followed. Patients trust doctors and will go along with this advice, eroding societies’ wellbeing and fanning health anxiety. Soon the natural extension of this logic will see a clammer for statins in ever younger age groups and for more aggressive treatment. Is “statins for all” bad medicine? Time will tell.
Our appetite for statins as a profession hinges on the ‘magical’ relative risk reductions that are quoted loudly and often. The fact most people are highly unlikely to benefit from these drugs and have significant risk of being harmed by them is conveniently forgotten.
References:
1. Spence D, et al. Bad medicine: statins BMJ 2013;346:f3566 [hr]
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