Initiatives in both the US and the UK look set to vastly increase the number of people deemed eligible for treatment with statins. While some seem to have welcomed these moves, there has been a lot of dissent too. Some believe that statins already have an unfavourable risk/benefit profile for people judged to be at low risk of having a heart attack or stroke. For those that hold this view (I am one of them), giving statins to people at even lower risk can seem crazy.
Take a casual surf online regarding these issues and you perhaps notice that many people opposed to ‘statination’ feel they have suffered at the hands of the medical profession and its ‘liberal’ use of statins. Others have never taken statins, but have come to the conclusion that the benefits of statins are likely outweighed by their risks, for them, and they therefore do not want to take them. Nevertheless, these individuals sometimes feel they are being put under inordinate pressure by their doctors to ‘comply’. Some will have been given dire warnings about the supposed risks of declining statins.
Sometimes feel compelled to remind individuals, though, doctors cannot force patients to take medication they do not want to take. Ultimately, once statins have been offered, the decision about whether the medication is taken or not is usually in the hands of the patient alone.
I was reminded of this fact while reading an opinion piece this week in the Journal of the American Medical Association, written by Yale University cardiologist and professor of medicine Harlan Krumholz . The piece explores some of the issues and controversies surrounding the recent cholesterol guidelines in the US (as well as issues concerning the guidelines related to blood pressure management).
In particular, Professor Krumholz makes the point that guidelines “should inform but not dictate, guide but not enforce, and support but not restrict.”
Professor Krumholz goes on to write that:
Guidelines can provide options and recommendations for those seeking to improve the quality and quantity of their lives. They can indicate strategies that are, in the opinion of the experts, outside of evidence and unworthy of pursuit. They can highlight points of uncertainty. But they should not reduce physicians to automatons and patients to passive recipients of guideline dictums.
Professor Krumholz makes some (what I believe to be) very sensible recommendations regarding the way forward, including an emphasis on producing evidence that who is likely to benefit most from treatment, and what trade-off risks there are too.
Interestingly, though, Professor Krumholz makes a strong call for the patient to be involved more in the decision making process. Under the recommendation to “Strengthen the Patient’s Voice”, he writes:
Finding ways to ensure that patients have agency over their decisions in ways that are genuine will be increasingly important. Patients and physicians need to work together, with the clinicians in a position to assist decisionsbut not impose choices. Physicians need to invite discussion, support informed choice, and instill patients with the courage to participate. Patients need to know that the medical facts alone are insufficient to determine what is right for them. Their context, preferences, values, and goals must be part of the decision if the final choice is to be in alignment with their best interests.
I have to admit, it’s not often that I read a comment pertaining to statin therapy from a cardiologist who does not seem frothingly enthusiastic about these drugs. Professor Krumholz should be commended for his seeming ability to think independently, and for his focus not on the supposed ‘need’ for treatment, but the needs and desires of real people.
1. Krumholz HM. The New Cholesterol and Blood Pressure Guidelines Perspective on the Path Forward JAMA published on line 29 March 2014