Is our faith in unproven cholesterol-reducing strategies due to brain-washing?

Recently, a brief article appeared in the British Medical Journal about how to manage the muscle pain (myalgia) that can occur in takers of the cholesterol-reducing drugs known as statins. The article itself describes this symptom as ‘common’, quoting an incidence of 5-10 per cent in published studies. However, my experience in practice is that this side-effect is more common. This might have something to do with the fact that in many published studies those prone to side-effects are screened out prior to the actual study getting underway. Also, researchers sometimes only log problems once blood test results are extremely abnormal, setting the bar very high for what would be registered as a ‘adverse effect’. You can read more about this here.

The article about myalgia in statin-takers was followed by a letter from a UK-based general practitioner (family physician) who questions why the original article does not mention the strategy of giving the statin rosuvastatin once-weekly rather than daily. This, apparently, makes myalgia less likely in those who do not tolerate statins, and ‘has been used for many years’.

I don’t deny that giving a statin one-weekly rather than daily would reduce the risk of side-effects, but what effect may this dosing regimen have on the purported benefits of statins? Are we to assume that the benefits will remain unaffected? I emailed the author of the letter about this. He responded and admitted he was not aware of any research which has looked at clinical endpoints (such as heart attack or death), and even included reference to a study which acknowledges this fact [2]. And then he went on to say: “…but assuming a class effect for statins then it seems that once weekly is preferable to no statin. Probably better than ezetimibe alone.”

‘Class effect’ is a term used to describe the idea that similar drugs (in this case statins) have very similar benefits (and risks). But any positive evidence we have on statins is based on once-daily dosing, so it seems to me to be a stretch to assume that once-weekly can be assumed to confer benefit. As we know, the vast majority of people who take statins daily will not benefit. It seems likely to me that the generally piffling benefits of statins would fade into insignificance if the drug is given weekly rather than daily.

I responded to the doctor essentially pointing this out, and also suggested that claiming that once-weekly rosuvastatin is probably better than ezetimibe alone is not saying much, seeing as ezetimibe has not been shown to have benefits on clinical outcomes. If anything, some studies suggest it may actually worsen health outcomes. In light of these things, I asked the doctor if he thinks that one-weekly dosing of rosuvastatin is ‘evidence-based’. Here’s his response:

I still feel that it is likely that there is a class effect for statins and this is not “stretching it a bit”. I think it is unlikely that anyone would be able to fund a study looking for outcomes for once weekly rosuvastatin or recruit the numbers required.

However before denying patients statin treatment I feel they should at least be offered this intervention. As you point out there are studies where ezetimibe had a negative effect and this is the drug that doctors are most likely to use when statins fail.

To which I replied that we’d have to agree to disagree on the class effect thing, and that while it’s good he is aware of the possibly harmful effects of ezetimibe, the real point is that ezetimibe has never been shown to provide clinical benefit. I also pressed him for an answer to my question about whether once-weekly rosuvastatin is evidence-based or not, adding: “A simple yes or no will do.”

His response was:

I think there is enough circumstantial evidence to justify this approach.

That’s not exactly the straight answer I had hoped for. And I don’t blame him, seeing as ‘yes’ would not be accurate, and ‘no’ would mean straight admitting the lack of evidence for this approach.

I honestly have nothing in particular against this doctor, and I suspect he believes he does his best for his patients. But what I think is going on here is something that is endemic in modern-day medicine: We doctors increasingly have had it drummed into us that what we do must be ‘evidence-based’. The reality, for the most part, is nothing could be further from the truth.

I also think that perhaps this doctor has fallen into the trap of believing that cholesterol reduction by whatever means and to whatever extent is inherently good for health. It’s got to the level where some people now believe that we don’t need to prove the benefits of a treatment, just a belief that it works will do. This is not just true of drugs: it reminds me of the marketing of cholesterol-lowering margarines that have never, ever been proven to benefit health.

My sense is that the pharmaceutical and food industries have done a fantastic job of diverting our attention away from what is truly important (health) to other things they can sell (such as cholesterol). Another term for this is “brain washing.”

References:

1. Lasker SS, et al. Myalgia while taking statins. BMJ (Published 14 August 2012)

2. Ruisinger JF, et al. Once-a-week rosuvastatin (2.5 to 20 mg) in patients with a previous statin intolerance. Am J Cardiol 2009;103(3):393-4

12 Responses to Is our faith in unproven cholesterol-reducing strategies due to brain-washing?

  1. Clare Casson 23 November 2012 at 1:04 pm #

    I’d agree with you that taking statins is not the ‘no brainer’ it is often presented as, given outcomes and numbers needed to treat. But if someone does opt to take them, there is some evidence – albeit limited – that CoEnzyme Q10 (CoQ10) therapy may help with statin-induced myalgia. As far as I’m aware taking CoQ10 has no side effects.

  2. peter Killingback 23 November 2012 at 3:23 pm #

    On this basis, why not just have one dose every month?, every year? or even once in a life time? So where does one draw the line between credibility and credulity? Ah…ha what we want is evidence based treatments, but you only get this from well designed and supervised clinical trials. It would seem there arnt too many of those about either! :) Back to anecdotal and clinical experience, if it works in some, try in others (and hope the patient doesnt die first)!! By thye way I’m not really a cynic!

  3. George Super BootCamps 23 November 2012 at 3:53 pm #

    “Is our faith in unproven cholesterol reducing strategies due to brain washing?”

    Simple answer, YES. Sadly. I’ve experienced way too many people who simply believe what they’ve been told, by those who don’t deserve to be trusted. And I’m talking about both doctors and their patients here.

    It’s thanks to people like Dr B that this is slowly changing.

    Keep up the good work,
    George

  4. Dr John Briffa 23 November 2012 at 4:22 pm #

    Peter

    Back to anecdotal and clinical experience

    Which would be OK sometimes, except that with cholesterol management it’s highly unlikely that clinical experience will be long and vast enough to make a judgment. All we have to rely on is the research, and there is no research which supports this approach. The doctor who wrote the original letter alerting us to this approach said so (but still believes there’s ‘circumstantial’ evidence which justifies it).

  5. George Super BootCamps 23 November 2012 at 4:50 pm #

    Dr J,

    Is there also an issue with docs where they prescribe (drugs like) statins because they might not know what else they can do that may help their patient?

    I don’t know either way, that’s why I ask.

    Cheers
    George

  6. Bill 23 November 2012 at 8:29 pm #

    I’m getting good results with delayed-release niacin, 1500 mg/day.
    Gave up the statin 4 years ago after a negative reaction.

  7. Marie 23 November 2012 at 9:11 pm #

    Are your prescription drugs killing you?

    Armon B. Neel, Jr. PharmD, CGP and Bill Hogan have written this interesting book.
    Armon Neel is very critical to the overprescribed statins and there are several patient stories to demonstrate side ffects.
    One chapter is called – Statin Roulette, drugs of last resort.
    Another one is called – Does dad really have Alzheimers?, a look at drug-induced dementia.

    Armon Neel is a board-certified pharmacist whose medical career has spanned four decades. He is AARP´s “Ask the Pharmacist” expert and lives in Georgia.
    Bill Hogan is an award-winning investigative journalist in Washington, DC. He has worked as a writer and consulting editor för the AARP Bulletin and as a consultant to CBS News.

    There are a few issues that I disagree with but on the whole I like the book and admire Mr. Neel for his work to protect the elderly against medication errors.

    My father was a multimedicated man and it was only, at the end of his life, that I realised that many of his problems could be side effects. I became very angry and since then I have learnt a lot.
    Without the Internet I wouldn´t have a clue about all interesting books and information.

  8. Lorna 24 November 2012 at 1:54 am #

    There’s another consequence here of using ‘raised’ cholesterol as a measure of ‘ill-health’: when a patient, who feels otherwise well, is told that their cholesterol is ‘too high’ it doesn’t just result in possible medication. The stress of being told that, despite feeling fine, the data says they are ‘under threat of future heart disease’ is an inducement to anxiety. Placing oneself uncritically in the hands of a computer-model of disease with debatable drugs is risky.
    Taking a larger dose of a drug once a week suggests that any side-effects would be intensified and/or more dramatic due to larger quantities of chemical intervention. Very interesting that the GP did not have any answers when asked to substantiate his views – how many other GPs are prescribing statins on this kind of unthinking trust in data ‘norms’ and pharmaceutical dogma?

  9. helen 25 November 2012 at 3:10 am #

    One can live a very full and happy life never getting a medical check up for anything!!! dying is something we all do to pass from this physical life we play at ….and taking these mind and body altering drugs does nothing to stop the experience of death so why is everyone thinking that drugs with unnatural harmful chemicals will prolong their lives and keep them healthy ………..they dont they really only ensure that vast numbers of people live marginally longer in greater sickness and discomfort than they would have normally. Fear all advertising is based on fear of having or not having something…………stop living in fear and just enjoy your lives for how ever long they are. and looking at averages and norms ….what the hell is that all about …..are we not all unique?? why then do we allow someone to tell us that something is normal or not normal what normal for you is not normal for me and vice versa.
    thanks Dr Briffa for reminding us all that we need to think and analyse and follow the money and question and keep ourselves informed you are awesome!!

  10. Paul 26 November 2012 at 2:14 pm #

    I chuckled when I red Dr Briffa’s reference to the marketing of cholesterol reducing margarines. For those who don’t remember, the television advert commenced with, “The reason that people who live in the Mediterranean live longer is due…….”.

    WHAT? Where did they get this statistic from. Did it apply to every Mediterranean country? Did it apply to all countries bordering the Med (ie, did it apply to Calais, as Calais is in a Mediterranean country)? At the time, I thought it was ridiculous, but the population swallowed both the marketing and the trans-fat.

  11. John B 1 December 2012 at 1:49 pm #

    It highlights what is wrong in much of so-called science, ‘feeling’ and ‘belief’ have replaced that bedrock of science, observable, falsifiable evidence.

    In effect it has become a religion and anyone who disagrees with the orthodoxy of those who ‘believe’ are heretic and anathema.

  12. Dave Wyman 10 February 2013 at 9:37 pm #

    “I’m getting good results with delayed-release niacin, 1500 mg/day.
    Gave up the statin 4 years ago after a negative reaction.”

    What are “good results?” Different numbers with cholesterol? I think there are no scientific data showing niacin helps people live longer and/or escape heart disease or heart attacks.

Leave a Reply