Statins

[Ivor the Engineer]

Here's an interesting presentation on cholesterol and heart disease:

http://uk.youtube.com/watch?v=i8SSCNaaDcE#GU5U2spHI_4

 

[Schneibster]

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

What aliment do statins treat?

High cholesterol, a proven risk factor for expensive and debilitating heart disease.

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

If they don't have the money to buy them, you propose not to pay for them with national healthcare. I think this is short-sighted, and a penalty on people whose appearance you don't like. I'm sorry you don't like fat people, but I don't think they deserve to die because you don't like them. I also think you haven't addressed my point about the eventual costs of the disease being higher than the cost of treatment. Which means you're weaseling when confronted with your own prejudices.

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 have no opinion on that; it's not the subject under discussion.

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

Correct, and if it is not treated, those conditions will occur, kill, disable, and cost lots more money than treating it would have. It's neither ethically nor financially justifiable.

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

You're making judgments that involve other peoples' lives and health, based on your own prejudices. You've lost a lot of cred with me over this. I think you'll lose plenty with other people too. You are attempting to justify withholding inexpensive treatment for a chronic condition that leads to expensive disability if untreated, on the grounds that the chronic condition is due to some moral fault of the people experiencing it, which isn't even scientifically true, much less ethically justifiable. You haven't got a leg to stand on, and the fact you haven't provided a lick of evidence to support your assertions, and have ignored evidence that in fact the proposed action to save money will actually wind up costing more, shows it.

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.

So? What do you want, kill them all if they're fat? Release the food police?

How much is that going to cost the NHS to treat?

Depends on whether they pay for statins, or for heart surgery, doesn't it?

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...

Again, what do you want to do? Withholding treatment for a chronic condition ain't it.

 

[Soapy Sam]

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

The latter.
(I also do take my general health a bit more seriously than I may have implied.)

ETA- While prescription of statins is one attempt at proactive medication which I applaud in the sense that it beats waiting till someone is actually ill, there are two aspects which trouble me. I think Ivor shares my concern.

1. There is something of a shotgun blast approach. I have privately asked eleven patients of the medical practice with which I'm registered. All are aged 45-60. All of them are either taking statins or have refused- but all were encouraged by the practice to take them. Yet when I asked a friend in another town, he polled seven friends and relatives in the same age range at his doctor. Not one had been offered or asked about statins. A tiny survey, I realise, but a curious discrepancy.
2. The attitude I suggested earlier, that people think "being on statins" is a licence to eat high cholesterol foods and stop exercising. (Honest, I was kidding about myself, but the thought does occur when I wander past the chocolate shelf).

In the UK in the last 15 years, the overall shape of the population has changed. The teenagers and sub-teens in particular are fat- sloppy and lacking any sort of muscle tone. They have bellies like poisoned dogs - often pointedly on display below tiny tops. They don't think they are fat, any more than we thought we were skinny. But many of the kids I was at school with, now in their fifties, are STILL slim. But their kids and grandkids are not.
Fast food, TV Dinners, shopping by car , 2 litre bottles of sugary carbonated drinks and " special value packs" (read "BIG") of high fat snacks.
At the same time, children have adopted a much lower energy lifestyle. It's just not cool to run around playing "tig" any more. Looking cool, wearing designer gear, hanging out at the mall and playing video games are the main pastimes. Static stuff.
I remember a few fat kids at school in the 60-70s, but they were notable as exceptions. Now they are , if not quite the norm, then at least extremely common.
We do need to change attitudes on this. If people get the idea they can live this way and stay healthy by taking pills, well, I can't see that as positive at all.
It's kind of ironic that the fat explosion is happening just as Brits are kicking the tobacco habit in ever greater numbers.

 

[Ivor the Engineer]

Schneibster:

I'm researching this at the moment and will be presenting what I've found here in the near future.

And I really don't know why you think I hate fat people. People can do exactly what they want to their bodies as far as I'm concerned. But I do expect them to pay for measures that mediate the risks they take.

I have serious doubts over the supposed cost benefits to the NHS by increasing the number of people on statins.

How many days longer does an individual live if they are on statins for "high" cholesterol?

What diseases are made more likely by low cholesterol?

Are you sure that statins help reduce the risk of CHD through their cholesterol lowering effects?

 

[Darat]

Ivor - as far as I was aware the claims for statins and the reason they are prescribed is to reduce the likelihood of serious cardiovascular problems. Consider a case of someone you consider has not "done enough" to reduce their cholesterol (and you will not prescribe them a statin) drops down in the street from a stroke.

Will you now refuse the ambulance, the emergency treatment (the very expensive immediate post-stroke medication), the months of recuperative treatment and then the long term disability payments because they can no longer work?

 

[Ivor the Engineer]

Ivor - as far as I was aware the claims for statins and the reason they are prescribed is to reduce the likelihood of serious cardiovascular problems. Consider a case of someone you consider has not "done enough" to reduce their cholesterol (and you will not prescribe them a statin) drops down in the street from a stroke.

Will you now refuse the ambulance, the emergency treatment (the very expensive immediate post-stroke medication), the months of recuperative treatment and then the long term disability payments because they can no longer work?

For the third(?) time:

No, all people should be treated without prejudice. I.e. no matter how they have lived their life up to the point they collapse, they should get exactly the same level of care as anyone else. This includes (but is not limited to): fat people, thin people, rapists, murders, lawyers, politicians and JREF forum moderators who keep on arguing with me Hell, even Linda too.

As for the cost benefit of statins to the NHS by avoiding treatment for strokes and heart attacks, especially the mass prescribing of them to groups at ever decreasing risk, I am not yet convinced they will bare the fruit many claim they will.

Then you have the side effects, claimed to be extremely rare. But is that because many are put down by doctors as related to age or other unrelated factors, when in fact they are related to the statins? E.g., there has already been a proposed link between low LDL and increased risk of Parkinson's disease.

 

[Schneibster]

Schneibster:

I'm researching this at the moment and will be presenting what I've found here in the near future.

I'm sure you'll find some woo study that says something bad about statins. Whatever.

And I really don't know why you think I hate fat people.

Because it's generally agreed that when someone shows prejudice against a class of people, they hate them, whether they admit it or not.

People can do exactly what they want to their bodies as far as I'm concerned. But I do expect them to pay for measures that mediate the risks they take.

Similarly, you are free to make whatever assumptions you care to about how people get certain conditions, no matter whether they have anything to do with reality or not. But I expect you to accept the fact that if you refuse to examine those assumptions, then others will identify you as prejudiced. That is, after all, what it means; you've pre-judged.

I have serious doubts over the supposed cost benefits to the NHS by increasing the number of people on statins.

And I have serious doubts as to the objectivity of someone who casts aspersions on treatments tested under double-blind protocols without having evidence in hand to support their assertions. Having to go looking for such evidence says that you have no idea right now whether it's true or not; and having had heart surgery myself, and seen the bills, and having paid for statins for several years, and seen the bills for that as well, I'd say that I have a good deal more knowledge on this subject than you do, or are likely to have anytime soon. And quite frankly, no matter how prejudiced you may be, I hope you never gain that knowledge the way I have.

How many days longer does an individual live if they are on statins for "high" cholesterol?

The question is, how often do people who have high cholesterol have heart attacks and strokes when they take statins, vs. when they do not? And the answer is, less often- that's why doctors prescribe them.

What diseases are made more likely by low cholesterol?

What does that have to do with anything? And what makes you think it has any effect at all, other than on women who are pregnant or nursing? As far as anyone can tell, those are the only people who risk anything by the clinical levels statins reduce cholesterol to.

Now, no doubt, if statins were used to reduce cholesterol to unusually low levels, some problem might result. But regular cholesterol testing ensures that that doesn't happen.

Are you sure that statins help reduce the risk of CHD through their cholesterol lowering effects?

I don't know what CHD is. The connection between statins and lowered risk of heart attack in people with high cholesterol is documented in double-blind testing. Whether that's because they lower cholesterol, or some other factor, is speculative, but the connection between taking them and lowered risk is well documented.

 

[casebro]

Here's the data as I see it: The longest term studies of statins are five years. During that time, the control group had a 7.5% death rate. The Statin group had a 5% death rate. That is a 33% improvement. Oh, they average 1 year longer. Sounds good, eh? But lets look at the same specs like this: 2 1/2% means that ONE out of forty people live longer. Forty people times five years is 200 patient years of treatment. For one patient year of life extension. That means that for you to live to be 76, instead of dying at 75, your great-great-great-grandfather had to start taking the statins in 1825.

But so far as the health care system goes, it means that they will delay paying for each angioplasty ($12,000 to $30,000) or a CBG surgery ($40,000-$60,000) for several months. The profits they make by investing the money in the mean time is what makes those huge businesses profitable. Especially when the patient pays the brunt of the drug cost. My HMO, even with Medicare Part D drug coverage, means I pay about 80% of generic drug costs.

Of course, for those with genetic hypercholesterolemia, your mileage may drastically improve. Hmmm, I wonder, if those few patients with genetic hypercholesterolemia were eliminated from the statin studies, if the drug would show no benefit for the rest of us? But the genetic hypercholesterolem-ics would show great improvements? Pharmacogenetics, when are you going to get here? Hmmm, not as long as the patient is paying for the drug, or 80% of it...

 

[Mashuna]

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

Yes, especially if it means they can save money on expensive cancer treatments and surgeries by giving out a cheaper drug as a preventative.

 

[Darat]

For the third(?) time:

No, all people should be treated without prejudice. I.e. no matter how they have lived their life up to the point they collapse, they should get exactly the same level of care as anyone else. This includes (but is not limited to): fat people, thin people, rapists, murders, lawyers, politicians and JREF forum moderators who keep on arguing with me Hell, even Linda too.

As for the cost benefit of statins to the NHS by avoiding treatment for strokes and heart attacks, especially the mass prescribing of them to groups at ever decreasing risk, I am not yet convinced they will bare the fruit many claim they will.

Then you have the side effects, claimed to be extremely rare. But is that because many are put down by doctors as related to age or other unrelated factors, when in fact they are related to the statins? E.g., there has already been a proposed link between low LDL and increased risk of Parkinson's disease.

Sorry I just can't follow your reasoning - you wish to deny people statins because they haven't done enough in your opinion to lower their cholesterol because it is expensive to the health service, yet we know that without statins a significant number of those people will suffer from serious cardiovascular disease yet you are quite happy to pick up the cost of treatment for that.... something doesn't seem to add up. You are willing to pay for the expensive treatments even though it is "self inflicted" but not willing to pay for the cheaper treatments because it is "self inflicted".

From what I've read the cost of a generic statin prescription for a patient for a year is around £25. If every man, woman and child in the country was prescribed statins tomorrow it would cost us £1.5 billion a year, heart disease alone costs us £29 billion a year.

Lets be more realistic, say all 50 year olds and above were prescribed statins so that would be around 20 million people in the UK, that would be a cost of £500,000,000 or half a billion, and if that only reduces the cost to the UK of heart attacks by 5% it would save the country almost one and a half billion net cost benefit of almost a billion pounds. (I really do hope I've got all my noughts correct else I'm going to look like rather silly!)

So even putting aside anything about ethics or morality prescribing statins (if they do as claimed) is a financially sound policy for the NHS.

 

[Ivor the Engineer]

Sorry I just can't follow your reasoning - you wish to deny people statins because they haven't done enough in your opinion to lower their cholesterol because it is expensive to the health service, yet we know that without statins a significant number of those people will suffer from serious cardiovascular disease yet you are quite happy to pick up the cost of treatment for that.... something doesn't seem to add up. You are willing to pay for the expensive treatments even though it is "self inflicted" but not willing to pay for the cheaper treatments because it is "self inflicted".

My opinion is that we are creating a sick society, which if things carry on the way they are going, will have almost every member of it taking medication for something. Statins look like being the first of the mass medications or ‘supplements’ huge numbers of people will urged to take. What will be the next risk the pharmaceutical companies are going to help us reduce in the easiest way possible? Why bother living a healthy lifestyle when the NHS will provide you with pills to help you avoid the long-term consequences of your actions? In the future will it even be possible to be classed as healthy unless you are taking risk-reducing medications? E.g., Americans are urged to achieve an LDL below 2mmol/l and total cholesterol below 4mmol/l. How many people would need to be medicated to achieve those figures?

From what I've read the cost of a generic statin prescription for a patient for a year is around £25. If every man, woman and child in the country was prescribed statins tomorrow it would cost us £1.5 billion a year, heart disease alone costs us £29 billion a year.

Lets be more realistic, say all 50 year olds and above were prescribed statins so that would be around 20 million people in the UK, that would be a cost of £500,000,000 or half a billion, and if that only reduces the cost to the UK of heart attacks by 5% it would save the country almost one and a half billion net cost benefit of almost a billion pounds. (I really do hope I've got all my noughts correct else I'm going to look like rather silly!)

So even putting aside anything about ethics or morality prescribing statins (if they do as claimed) is a financially sound policy for the NHS.

The total drug budget for the NHS is ‘only’ £8bn./year So statins, even if only prescribed for over 50’s, statins would be over 6% of the total drug budget. Factoring in other costs and people on statins, that's about £1bn./year spent on drugs and other treatments so people can have a reduced risk of CHD while maintaining an unhealthy lifestyle that increases the risk.

A flaw in your reasoning is assuming that all those people who avoid heart attacks do not end up suffering from other chronic illnesses that need even more expensive drugs and treatment. E.g., how much does cancer cost to treat? How much do hip replacements cost? How much does diabetes (and related complications) treatment cost? The list is endless.

For the NHS to slow the increase in spending the population needs to become healthier, not more medicated.

 

[Darat]

My opinion is that we are creating a sick society,

...snip...

Yet today before we have this widespread prescribing of statins that you think will create a "sick society" the cost of cardiovascular disease is put at £29 billion. It would seem the "sick society" is already here.

 

[Ivor the Engineer]

Yet today before we have this widespread prescribing of statins that you think will create a "sick society" the cost of cardiovascular disease is put at £29 billion. It would seem the "sick society" is already here.

And dishing out ever more statins (about 4 million take them at the moment in the UK) is not going to make it go away.

ETA: From a pharmaceutical company point of view, it may even be worth giving them away, since people will live long enough to get cancer, which as we all know, is where the real money is.

 

[Darat]

Sorry your reasoning is now totally beyond me - you are now seeming to say it is bad to keep people alive because that will mean they only get more expensive illnesses! So you are saying that "people who do not adjust their lifestyle should be allowed to die even if we have a cheap effective treatment that would keep more of them alive".

Which ever way you slice it Ivor you are saying that treatment should be withheld based on whether people live a lifestyle you approve of.

 

[casebro]

Soooo, if our average age of deaths from heart disease is 75, but our average age of death from cancer is 60, then if we cure heart disease then we will all die younger from cancer?

Anyway, statins have been on the market for 20 years now. 40% of us still die from heart disease. It just takes a couple months longer. Remember, 2 1/2% of us life a year longer, thats NINE days each averaged out amongst us all. At what cost? At $50/month, for 5 years, thats $3,000 for NINE days. Each. Or $333 per day.

Can our economies support $333 per day for each of us? Where will the money for shiney new cars come from? Or to buy Britney's newest album?

 

[Ivor the Engineer]

Sorry your reasoning is now totally beyond me - you are now seeming to say it is bad to keep people alive because that will mean they only get more expensive illnesses! So you are saying that "people who do not adjust their lifestyle should be allowed to die even if we have a cheap effective treatment that would keep more of them alive".

Which ever way you slice it Ivor you are saying that treatment should be withheld based on whether people live a lifestyle you approve of.

What I'm saying is ultimately you don't keep them alive or healthy for longer because their risk of other diseases is increased by their unhealthy lifestyle. All you end up doing is trading one cause of death for another, with minimal reductions in morbidity or mortality.

 

[Ivor the Engineer]

Here's some enlightening (if somewhat depressing) reading on the risk factors associated with heart disease and their increase over time in the UK and the rest of the world:

http://www.heartstats.org/temp/2006spwholespdocumenths2hs.pdf

ETA: Not the latest one! This one is:

http://www.heartstats.org/uploads/documents\48160_text_05_06_07.pdf

 

[krazyKemist]

Well, anyway, cholesterol is very badly absorbed in food. Most of our cholesterol comes from our own biosynthesis, that's why statins are so efficient and low-cholesterol diets often fail. Some foods can lower LDL levels, tending to act like statins (like grapefruit which contains a weak P450 inhibitor).

And it kind of get on my nerves earing people talk about "cholesterol" rather than LDL. We synthesize cholesterol because we need it (it is the precursor of all sex hormones, corticoids, and is essential in cell membranes, more so in the skin). LDL (Low-density lipoprotein) is the transport form that seem to cause problems when in too high concentrations.

Another thing is that atherosclerosis is actually a degenerative disease, with a strong inflammatory component, and that LDL levels are a very poor predictor for it. The mayor of my city, a lady of about 70 years old, died very suddenly of heart attack with perfect LDL level and blood pressure. She was also quite active and was not obese.

the Kemist

 

[Darat]

Here's some enlightening (if somewhat depressing) reading on the risk factors associated with heart disease and their increase over time in the UK and the rest of the world:

http://www.heartstats.org/temp/2006spwholespdocumenths2hs.pdf

ETA: Not the latest one! This one is:

http://www.heartstats.org/uploads/documents\48160_text_05_06_07.pdf

I take it from reading that report that you will also be advocating that if people don't change their lifestyle by moving up the socio-economic ladder they also shouldn't be given statins..... ?

 

[juniper_ann]

Isn’t this really the “abstention-only” argument, with the target changed from “horny teenagers” to “fat slobs?” After all, if you give the kids condoms they’re only going to use them, but if you don’t, they’ll all be models of purity who arrive at their wedding nights unsullied and completely free of babies and diseases.

It might be a nice theory, but this here is the real world where some people can’t or won’t or don’t know how to lose weight. This is the world where people are fat because they have low literacy and little access to health information, or because the traditional food of their homeland is laden with excess calories, or because they have to work two jobs and literally have no time for exercise, or maybe because they’re depressed and use food as a comfort item but don’t feel up to exercising.

No study has ever successfully shown a four-year maintenance of weight loss. Certainly, it’s happened outside of studies, so it’s possible, but it’s not that simple.