Statins

[Quavergirl]

Statins--the Country Doc view

I'm a cardiologist and use statins daily. There is a tremenous amount of data supporting their use (i.e. less dead bodies) and good documentation of their known side effects and therapeutic limitations (which I respect). More about that later if you are interested. Personally, I tailor the use of these drugs to each and every different patient sitting in front of me. A doc has to "adapt" guidelines--that is, be a "doctor", not just parrot the party line.*

I find the the development of statins fascinating. There was a little girl named Stormy Jones. She developed throat pain at age 8--thought to be a sore throat initially. Turns out she was having a heart attack. She was missing both copies of her LDL receptor gene in her liver; she had homozygous familial hyperlipidemia (about 1:1,000,000 incidence). Total cholesterol in these cases run in the 600-800 (sorry--US units) range and the patients develop physical signs of the cholesterol burden in their bodies. She was studied by some guys from Texas (Brown and Goldstein) They later won a Nobel Prize for ID'ing the LDL receptor. Stormy, however, died. Her doctors reasoned that a liver transplant would "cure" her LDL receptor problem, but they also needed to transplant her heart which had been destroyed by multiple heart attacks. They tried a heart-liver transplant but she did not survive.

Statins were thus created to force the liver to create more LDL receptors. They work great on heterozygous familial hyperlipidemia (missing one LDL receptor gene, incidence about 1:500 !!, LDLs run about 180-220) because there is at least one allele present to make more LDL receptors.

You can just wave a statin in front of those people and drop their LDLs in half. Patients with different genetic and non-genetic contributors to elevated LDL respond in a variable fashion--hence the need to customize therapy.

LDL reduction is not the entire story of why people die less as well as have fewer heart attacks and strokes while on statins. There are pleotropic effects of these drugs (anti-inflammatory perhaps?) that come into play and reduce "hard" events (We cardiologists are simple folk--we count the hard events like death, heart attack and stroke. Other fields are too soft--for example, an oncologist claiming that a cancer has a 30% "response" rate to a drug--what does that mean?? Does the patient live one day longer??) Anyway, LDL reduction alone does not account for the rapid drops in hard events seen in the big trials (tens of thousands of patients).

Q

*I also have a kid with autism, so my "faith" in popular medical science interpretation has been deeply shaken--more than every before I review the medical literature with the intent of weeding out the politics. Medicine is as subject to fads and mistaken "consensus" as is every other field (remember low-fat diets?)

 

[Darat]

The former - I think statins should not be offered to people who refuse to alter the aspects of their lifestyle that are likely to be causing them to have elevated cholesterol levels.

At least in the UK, GP's appear to be handing statins out like smarties at the moment.

...snip...

Where do you get that impression from? There are quite comprehensive guidelines about who a Doctor should prescribe statins to (off the top of my head if I recall correctly it's people that are calculated to have a 1 in 5 chance of a heart attack or stroke within the next 10 years).

And I do not want to have a health service that would (if it followed your views) decide that people should die or be left severely disabled for the rest of their life simply because they didn't quite manage to lose the "X" pounds indicated by your guidelines.


ETA: UK Guidelines:

...snip..

The new NICE guidelines (January 2006) propose statins for secondary prevention
of cardiovascular disease and primary prevention for individuals with ≥20% 10 year
cardiovascular risk. They also state that the statin with the lowest acquisition cost
be used. Initial estimates are the guidelines make 1 in 4 of the population aged 30
to 75 eligible.

...snip....

 

[Soapy Sam]

There are a lot of folks of Northern European extraction who have high cholesterol not because they eat bad stuff, but because their bodies make it, specifically their livers. I'm one of them, which is how I know about it. It doesn't matter what I eat or how much I exercise.

Be careful stereotyping, Ivor. There is a significant number of people who aren't sedentary and eat good diets and still have high cholesterol.

Bingo! My family for example. Mind you, this is not an excuse to stop exercising.

Land of the deep-fried Mars bar

Average life expectancy in Glasgow for males 68. Government proposes to raise retirement age to 69.

You have to die of something. It may as well taste good.

 

[Quavergirl]

Physician judges/Witholding therapy

To address the OP:

Withholding therapy due to disapproval of lifestyle is unethical. And it's a slippery slope that I (and I suspect most doctors) are not willing to step on. If third party payers/governments don't want to PAY for therapy to ameliorate the "wages of sin" that is an entirely different issue. But as a physician, I'm not a judge. I'm here to treat people with diseases/injuries (however acquired)

I'm pondering the ramifications of judgmental medicine. I'm not willing to:

1. Withhold statins or diabetic medication from obese/sedentary people
2. Withhold antibiotics from the septic woman after a botched abortion
3. Withhold surgery from the person shot while robbing a bank or shooting someone
4. Withold lung cancer surgery from the smoker
5. Withhold anti-HIV drugs from persons engaging in anal sex
6. Withold STD therapy from the child molestor
7. Withold birth control in an unmarried woman
8. Withold skin cancer surgery in the sun-worshipper
9. Withold breast cancer therapy in the HRT taker
10. Withold cervical cancer therapy in the prostitute
11. Withold prostate cancer therapy in the celibate
12. Withold surgery from the crashed drunk driver
13. Withold surgery from Darwin award nominees
14. Withold treatment from the unvaccinated

I'm certainly not shy about advising/lecturing/berating people into trying to make lifestyle changes, but I have to treat regardless. We do not know as much as we think we do about the etiology of disease. There is always marked uncertainty as to the exact contribution of lifestyle to certain problems; disease happens to the best of us. Disease is not an accurate judge of character.

Q

 

[Ivor the Engineer]

<snip>

And I do not want to have a health service that would (if it followed your views) decide that people should die or be left severely disabled for the rest of their life simply because they didn't quite manage to lose the "X" pounds indicated by your guidelines.

<snip>

Everyone is going to die of something. In the UK, it is likely to be quite a long and costly affair too. Do statins increase the cost to the health service by letting people who would have died in their 50's of a heart attack, linger on with ever increasing health problems because they have failed to address basic issues, constantly brought to their attention, such as weight, smoking, diet and exercise? Is there anything people are expected to take responsibility for with regards to their health?

On the other issue I brought up: Given the number of people with cholesterol levels above the recommended 4 mmol/l, is this a fundimental flaw with human biochemistry? Or is it a flaw with modern diet and activity levels? Are statins tackling the ultimate cause of the problem for most people? If not, what other problems are going to occur by ignoring the root cause(s)?

 

[Ivor the Engineer]

To address the OP:

Withholding therapy due to disapproval of lifestyle is unethical. And it's a slippery slope that I (and I suspect most doctors) are not willing to step on. If third party payers/governments don't want to PAY for therapy to ameliorate the "wages of sin" that is an entirely different issue. But as a physician, I'm not a judge. I'm here to treat people with diseases/injuries (however acquired)

I'm pondering the ramifications of judgmental medicine. I'm not willing to:

1. Withhold statins or diabetic medication from obese/sedentary people
2. Withhold antibiotics from the septic woman after a botched abortion
3. Withhold surgery from the person shot while robbing a bank or shooting someone
4. Withold lung cancer surgery from the smoker
5. Withhold anti-HIV drugs from persons engaging in anal sex
6. Withold STD therapy from the child molestor
7. Withold birth control in an unmarried woman
8. Withold skin cancer surgery in the sun-worshipper
9. Withold breast cancer therapy in the HRT taker
10. Withold cervical cancer therapy in the prostitute
11. Withold prostate cancer therapy in the celibate
12. Withold surgery from the crashed drunk driver
13. Withold surgery from Darwin award nominees
14. Withold treatment from the unvaccinated

I'm certainly not shy about advising/lecturing/berating people into trying to make lifestyle changes, but I have to treat regardless. We do not know as much as we think we do about the etiology of disease. There is always marked uncertainty as to the exact contribution of lifestyle to certain problems; disease happens to the best of us. Disease is not an accurate judge of character.

Q

Statins provide a risk reduction. There are often other personal behaviour modifications that would offer similar risk reductions. Before a person gets statins, they should have adjusted their behaviour to minimize their risk. If after doing this they still have an elevated cholesterol level, then treatment with statins should begin.

Everyone should be treated for acute and chronic illness, without prejudice. Not everyone should be provided with risk-reducing drugs if they refuse to take basic steps to reduce the risk first.

 

[Graham Jackman]

Everyone is going to die of something. In the UK, it is likely to be quite a long and costly affair too. Do statins increase the cost to the health service by letting people who would have died in their 50's of a heart attack, linger on with ever increasing health problems because they have failed to address basic issues, constantly brought to their attention, such as weight, smoking, diet and exercise? Is there anything people are expected to take responsibility for with regards to their health?

On the other issue I brought up: Given the number of people with cholesterol levels above the recommended 4 mmol/l, is this a fundimental flaw with human biochemistry? Or is it a flaw with modern diet and activity levels? Are statins tackling the ultimate cause of the problem for most people? If not, what other problems are going to occur by ignoring the root cause(s)?

A major problem with relying on cholesterol measurement is that shows a wide normal variation and is only poorlky correlated with risk, unless you happen to have familial hypercholesterolaemia. The major risk factors for cardiovascular disease are; family history, smoking, diabetes, hypertension and obesity. I may be overweight, but not obese and have no other risk factor than a cholesterol about 7 mmolar. I refuse to take statins because I do not see them offering me any major benefit and side effects of the treatment are common.
On an earlier comment about egg yolks. They do contain cholesterol, but studies have shown that cholesterol intake does not affect plasma cholesterol unless it exceeds the amount normally synthesised. This equates to about 1.5g or 6 eggs a day. What does influence cholesterol measurements is intake of saturated fats. As part of a study I ate 4 eggs a day for a month and I'd happily do it again.

 

[Mashuna]

The former - I think statins should not be offered to people who refuse to alter the aspects of their lifestyle that are likely to be causing them to have elevated cholesterol levels.

Well, Quavergirl's already said it better than I'm about to, but would you extend this line of thinking to, say, smokers with lung cancer?

 

[Schneibster]

Not everyone should be provided with risk-reducing drugs if they refuse to take basic steps to reduce the risk first.

You have ignored ethical problems that would land you in prison, or else with your pants sued off, in any liberal democracy on the planet. Welcome to the real world.

 

[Ivor the Engineer]

Well, Quavergirl's already said it better than I'm about to, but would you extend this line of thinking to, say, smokers with lung cancer?

Everyone should be treated for acute and chronic illness, without prejudice. Not everyone should be provided with risk-reducing drugs if they refuse to take basic steps to reduce the risk first.

Does that answer your question?

To put it another way, I don't expect the NHS to provide me with a helmet when I hurl myself down an icy hill on two planks of wood.

 

[Ivor the Engineer]

You have ignored ethical problems that would land you in prison, or else with your pants sued off, in any liberal democracy on the planet. Welcome to the real world.

What ethical problems? I'm not saying people should not have access to statins, just that a state funded system should not pay for them if the individual is not going to take basic precautions themselves first. If they want to lead a lifestyle that puts them at increased risk and use statins to mediate that risk, then they should pay for the drugs, not the state.

 

[Schneibster]

What ethical problems? I'm not saying people should not have access to statins, just that a state funded system should not pay for them if the individual is not going to take basic precautions themselves first. If they want to lead a lifestyle that puts them at increased risk and use statins to mediate that risk, then they should pay for the drugs, not the state.

OK, what's your fool-proof treatment for people who overeat, so they can get the statins they can't afford to pay for? You haven't thought your way through this. It's bad ethics. You can't withhold medical treatment, and it doesn't matter if the problem is self-inflicted. It's against the Hippocratic Oath.

 

[Ivor the Engineer]

OK, what's your fool-proof treatment for people who overeat, so they can get the statins they can't afford to pay for? You haven't thought your way through this. It's bad ethics. You can't withhold medical treatment, and it doesn't matter if the problem is self-inflicted. It's against the Hippocratic Oath.

Is overeating a disease? If an individual has a disease then they should be treated for that disease, no matter what they have done to get it.

Self-inflicted high cholesterol is not a disease. It is a risk factor in getting a disease.

 

[Schneibster]

Sorry, Ivor, not interested in the death penalty for fat people.

 

[Soapy Sam]

Not even if they wear Lycra leggings? You can take tolerance too far.

Schneibster- the NHS system provides drugs like statins free only to those qualified for financial reasons to get them. (The elderly, unemployed, pregnant, the likely categories.)
Although I have been prescribed statins by my NHS doc., I do have to pay for them , as an employed person.
Incidentally- do US doctors actually swear an oath of any sort on qualifying? I'm told they don't here.

 

[Ivor the Engineer]

Not even if they wear Lycra leggings? You can take tolerance too far.

Schneibster- the NHS system provides drugs like statins free only to those qualified for financial reasons to get them. (The elderly, unemployed, pregnant, the likely categories.)
Although I have been prescribed statins by my NHS doc., I do have to pay for them , as an employed person.
Incidentally- do US doctors actually swear an oath of any sort on qualifying? I'm told they don't here.

When you say 'pay', do you mean the full price, or the standard prescription charge?

 

[Ivor the Engineer]

Sorry, Ivor, not interested in the death penalty for fat people.

Neither am I. That is why they should be helped to get their weight down, exercise more and have a healthier diet. What they should *not* be given is little magic pills that allow them an excuse to carry on eating too much, having crap diets and taking little exercise simply because one measurement of their biochemistry has dropped to within the "normal" range.

If there was a drug that smokers could take to reduce their likelihood of getting lung cancer, should a public health system subsidize it?

How reckless to individual health does an behaviour have to be before a state health system should stop using resources to help mediate the risk from that behaviour?

 

[Schneibster]

Helped how? What do you suggest we do that we're not already doing? The information is out there; freedom implies that people make their own choices. All we can do is tell them the consequences of their behavior; it's up to them to do something about it. Withholding medical treatment is not an ethically justifiable behavior modification option. Neither doctors nor health plan administrators would make good Orwellian fat police. And the consequences here are death or lifelong disability. That's the death penalty for fat people, and nothing you've said so far sways my opinion.

I'll also point out that if someone doesn't die, they are permanently disabled and require long term treatment that costs a lot more than the pills would. Not to mention being incapable of holding a job and therefore eligible for free treatment, instead of helping defray the costs. So, the question is not, would you rather pay for pills for fat people or not, but, would you rather pay a little for pills for fat people, or a lot for treatment of those people after they have heart attacks? Leaving aside consideration of their welfare, it's STILL not justifiable.

 

[SYLVESTER1592]

I don't want to kick anyone in the shins boxedin: expecting Linda flaming anytime now ) , but internal medicine ( except infectious disease) is in most cases postponing the inevitable. Most typical diseases in internal medicine are crippling chronic diseases and are treated in a way that plays the numbers. You use treatments that have shown to reduce risk or improve the outcome in large populations. You don't necessarily cure people in the sense that the underlying disease is eliminated, but lengthen the patients lives and hope they can function better during this increased survival period. If you are successful, the patient dies at an old age from something else entirely without ever having experienced serious problems from the chronic disease. This is effectively a cure of the problem (not the disease).

The addition of statines is exactly that, playing the numbers, reduce the risk factors. If you have an illness that is related to a high cholesterol, the addition of statines can be part of the treatment regimen.

Many drugs have this idea in mind. All of these other drugs are usually covered for the appropriate indication (as long as the effects have been proven).

Since there is no wonder-pill that cures all underlying disease or a magic drug that brings the dead to life, a cure in the form of medication is in most cases some form of symptom and risk control.

(Cowardly hiding from the flame war )

SYL

 

[Ivor the Engineer]

Helped how? What do you suggest we do that we're not already doing? The information is out there; freedom implies that people make their own choices. All we can do is tell them the consequences of their behavior; it's up to them to do something about it. Withholding medical treatment is not an ethically justifiable behavior modification option. Neither doctors nor health plan administrators would make good Orwellian fat police. And the consequences here are death or lifelong disability. That's the death penalty for fat people, and nothing you've said so far sways my opinion.

I don't know why you keep on saying I'm advocating withholding treatment.

What aliment do statins treat?

How is anything I have said stopping people who want to take statins buying them?

As for what we should be doing, how about tax on (fast) food which does not meet certain standards? E.g. Make a burger and chips more expensive than the healthier options on the menu?

I'll also point out that if someone doesn't die, they are permanently disabled and require long term treatment that costs a lot more than the pills would. Not to mention being incapable of holding a job and therefore eligible for free treatment, instead of helping defray the costs. So, the question is not, would you rather pay for pills for fat people or not, but, would you rather pay a little for pills for fat people, or a lot for treatment of those people after they have heart attacks? Leaving aside consideration of their welfare, it's STILL not justifiable.

No one dies or is disabled by high cholesterol. It is a risk factor for conditions that do kill or disable.

People trade risk. If they know statins keep their cholesterol level ok, they will compensate.

There has been a report released recently which concludes that if the current trend continues, over half of the adult population in the UK will be obese by 2050.

How much is that going to cost the NHS to treat? Obviously they will all be on statins for life from the age of 35, diabetes medication from the age of 40, having their first hip replacements at age 50...