Earlier this year, the National Institute for Health and Care Excellence (NICE) suggested a reduction in the threshold beyond which statin therapy should be considered (from a 10-year risk of cardiovascular disease of 20 per cent to 10 per cent). Some people believe this can only be a good thing. I believe that these people generally haven’t embraced the evidence in the area and/or hopelessly biased.
The fact is hardly anyone at low risk if cardiovascular disease will benefit from taking statins. And of course they’re not without risk. But we don’t really know what the risks are because, as I’ve pointed out before, the research is conceived, designed, conducted and reported in ways which mean adverse effects will simply not be logged or ‘go missing’.
Last week, the British Medical Journal carried an interesting opinion piece from Professor Azeem Majeed – a general practitioner and professor of primary care based in London, UK . In his piece, Professor Majeed details three major objections to the widening of statin prescription to people at lower risk.
He first points to the fact that the proportion of health budget spent on primary care (general practice) has fallen. Also, it is well known that primary care doctors and services are placed under increasing demand. I can’t remember meeting a GP (family physician) in recent times who has not confessed to finding their workload and government-imposed requirements as very onerous. Professor Majeed writes:
…despite already being overstretched and underfunded, general practices will have other major new areas of work to take on, such as hospital admission avoidance schemes, improved care for older patients, longer opening hours, and more rapid access for people with acute medical problems. General practices may not be able to cope with all these additional areas of work and at the same time further expand access to statins unless the government were to increase the funding that general practices receive.
The second point Professor Majeed makes is that essentially healthy people may need to be ‘persuaded’ to take statins. My my experience tells me that most healthy individuals who take statins do so because they are scared not to. Usually, their doctor has given them a thoroughly jaundiced view of the value of the statins and the likely benefits. My experience is that when individuals are given the facts based on research (not rhetoric), they almost universally choose to give statins a miss. One could argue that if statins really were as effective as some doctors and researchers like to claim, then little persuasion would be necessary.
The final point Professor Majeed makes concerns the thorny subject of side-effects. In essence, he asks if we really know what the risks of taking statins are. He draws our attention to the fact that there appears to be a higher incidence of side effects in real world settings compared to that yielded by clinical trials. But, as we know, there are many reasons why this may be so (as I alluded to in the second paragraph). Professor Majeed comments that:
The discordance between the evidence from clinical trials and from clinical practice needs to be investigated so that doctors and patients are given accurate information about the risks and benefits of long term statin treatment.
To my mind, Professor Majeed’s is a thoughtful piece about why some have major reservations about the planned expansion of statin prescribing. It comes from someone who works on the front line, and perhaps knows the futility of trying to ‘sell’ patients a treatment which is quite ineffective and the safety of which is in doubt.
1. Majeed A. Statins for primary prevention of cardiovascular disease. BMJ 2014;348:g3491