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Location: Lurking within the psyche of Dave Sawdon
Statins - miracle or menace?
Having had a medical hiccup it's been suggested that I should take statins (despite not having high cholesterol) on the basis that there is apparently some evidence that they are generally a "good thing". When I look around I see people saying they're dreadful, cause memory loss, and might be the cause of nearly half the world's ailments.
What's the opinion of the medical pilot community on statins? (references to back-up assertions would be good!)
Medicine generally tends not to extend life. It's got it's place when one get's mangled up on the M6, put apart from that, there are only a few occasions when it actually makes much of a difference.
Immunisations work well, the "golden hour" saves a few lives, and fiddling about with peoples blood pressure/sugar levels may make a bit of a difference.
The other stuff we spend your money on could perhaps be spent on other areas.
Statin's however, seem to save lives. The odd recipient may suffer liver problems/ muscle problems, but in reality I haven't seen much evidence of this, and nowadays, the monitoring we use, seems to pick these problems up quickly.
They do seem to have a "magical" effect that we perhaps don't understand just yet.
I suspect the issue surrounds itself around the arbitrary number given to when lipids become a "problem."
In secondary prevention, (ie when you've already had your heart attack/stroke), reduction in lipid levels (irrespective of starting point) seems to reduce further events.
Primary prevention (ie preventing events in those who are otherwise healthy), does also seem to be supported by a robust body of evidence, although I'd be the first to admit that the tools designed to take into account other factors such as smoking, age, family history, blood pressure etc) are far from perfect.
It seems to me, gingernut, that it's another example of pulling together a committee, then coming up with a recommendation that keeps the majority happy. So it was decided that seeing as how the downside of drug therapy is low, the threshold for treatment could be lowered. And then if you lower it enough, then everyone over 50 will have a 10 year cardiac disease risk high enough to cross the threshold.
Unfortunately history shows that in most of medicine if you think you have the final answer, it'll turn out in the future to be completely wrong. (Think "mammograms" and "PSA")
And today we are often guilty of assuming that the most recent "study" is correct, even if it negates the previous 25 studies. That's usually because the recent study was not one at all, just a "meta-analysis" (i.e. a rejiggering of the data).
First they reduce cholesterol in people with hi levels and this is shown to be beneficial
There ae also two large studies showing that if given to people with normal cholesterol and no increased risk factors, the death rate from strokes and heart attacks was reduced
A large multi centre study coordinated by Oxford was released two weeks ago. It not only confirmed this but also clearly showed that the only significant side effect was myalgia or muscle pains which is a condition that stops if you stop statins
Sadly people will say statins are pushed by drug companies or committees but the science speaks for itself. Of course everyone can make up their own mind and there is no compulsion to take them but it verges on the immoral to frighten people from taking them when the evidence does not support this stance
It's refreshing to meet someone as cynical as myself obsgraham. I'd agree there is never "the final answer," provided by research, and of course, we can never "prove" or "disprove" our interventions absolutely, but I think where we have moved on, is that we are using more robust evidence, relying on realistic outcome measures, (such as the Grade 1 RCT's in statin intervention), and are less likely to rely on studies of poor design, using proxy outcome measures (which don't translate to clinical benefit), or even worse "expert opinion."
A meta analysis or systematic review shouldn't automatically refute the past 25 studies, it should add collective weight to the accuracy (or innacuracy) of the previous studies.
The RCGP stuff I cited does rely on high quality studies.
The decision to offer statins to those of CVD risk of 20% or above (in 10yrs), was made by a committee- I suspect this was made on the basis of cost, rather than clinical effectiveness, and I accept,the method we use to establish the risk calculation is far from perfect. (Although better than what we had before.)
Once you've been on a statin such as Crestor for a while, the evil cholesterol levels within you will begin to decrease. When you've been on Crestor for a long time, the furring of the arteries, caused by the previously mentioned nasty cholesterol, will slowly begin to reduce. Something else will kill you when you least see it coming but anything which reduces the chances being a stroke victim and unable to get along to Dignitas is to be taken with relish if not tomato sauce and tabasco.
I was told my local surgery's computer had decided I should take Pravastatin. I pointed out my Cholesterol level was 3.9 so did I need it? Well I was persuaded I would benefit from its use. Since taking it my hair has fallen out at a much quicker rate than normal, I have massive muscular pains and at present have a particularly nasty intercostal muscle [right side] that has spasms that make me gasp [squeak loudly!] in pain. I am cutting down over a 4 week period and telling my doc when it is done. My arteries are apparently 'clean and clear of any clag' according to my cardio.
Location: Lurking within the psyche of Dave Sawdon
Thanks for the link to the guidance document; it isn't exactly a fun read but I got through the majority of the bits that seemed relevant. Having read the guidance I didn't feel convinced that the evidence was sufficiently strong for someone with "normal" cholesterol levels to risk the side effects (documented in spacedoc.com, gpnotebook and elsewhere), especially as the reported beneficial mechanism for this group seems not to be fully understood.
Maybe this is a case of a (very) little knowledge being a dangerous thing, but ... I was confused by a couple of statements in the GPnotebook guidance: "It is hypothesised that there are two types of atherosclerotic lesions: atherotic (soft, lipid rich, there is often inflammation which destabilises the plaque's fibrous cap, the risk of plaque rupture makes these dangerous) and sclerotic (hard, collagen-rich, these are safe). The statin family of drugs alters the characteristics of the lipid core and reduces inflammation. The fibrous cap is stabilised preventing rupture. The total volume of the plaque may remain unchanged." Yet it also says: "... however, no statistically significant differences were seen for cardiovascular mortality or stroke". Elsewhere I've read that a rupturing atherosclerotic lesion can lead to stroke so if the hypothesis about statins stabilising the lesion is correct why has no significant improvement in stroke rate been seen?
hugh flung, it's a little difficult to give specific advice to someone via this forum.
I'm imagining that you've been prescribed pravastatin for a very good reason, (ie you've suffered some type of "event" already), as pravastatin isn't generlly used in primary prevention. It is important that you communicate your concerns to your docs.
My comment about pouring the stuff in the water does have to be taken with a pinch of salt, statins have been associated with serious side effects, muscle damage and liver damage being the ones that spring to mind.
I'm involved with statin prescribing/monitoring on a daily basis, and whilst I've seen the benefits of statin prescribing, (ie less people dropping dead or becoming disabled through stroke and heart disease), I don't think I've ever come across a case of statin induced muscle damage or liver problems.
Having said that, it is important to differentiate between a side effect, (eg aching legs) and disease (eg rhabdomyolysis), and your clinician should, hopefully have monitoring systems in place to detect these.
I haven't the expertise to answer your question about the nature of the atherosclerosis, but in a way, it's of secondary importance, as the outcome (ie reduction of risk of further "event") is more important than the process behind it. (We know it works, were not quite sure how.)
Location: Lurking within the psyche of Dave Sawdon
Thanks gingernut. To be clear: I'm not looking for advice (just to understood what's on each side of the risk/benefit balance) and I haven't been prescribed anything (it's been suggested that a statin might be beneficial, despite not having high cholesterol levels). That link is very positive about the benefits of statins but the NICE guidance - statins for the prevention of cardiovascular events says "for patients without clinical evidence of CHD, statins significantly reduced all-cause mortality ... however, no statistically significant differences were seen for cardiovascular mortality or stroke". To a medical layman this seems to be at odds with the guidance in the "CVA and Lipids" guidance - what have I missed? If there isn't a known mechanism, and the stats don't show any significant differences, then what's the compelling evidence that justifies the risk of even minor side effects?
"primary prevention for patients without clinical evidence of CHD, statins significantly reduced all-cause mortality, fatal MI and non-fatal MI in the meta-analysis carried out for the NICE appraisal however, no statistically significant differences were seen for cardiovascular mortality or stroke" Yes, it seems a confusing stance. As far as I can gather, statistical significance concerns itself with academic "proof" (ie more than 95% sure of certainty-or more technically, less than 5% percent of innacuracy), whereas the bottom line revolves around "clinical significance," ie the ability to to do what it says on the tin. It works the other way round as well. I once looked at some statistics around smoking cessation-the intervention showed a statistically significant difference in the number of cig's smoked-when we looked at this in more detail, the amount of cig's smoked was reduced from 20 a day, to 18. Statistically significant-yes, clinically significant-no. (in other words, the cig's will still kill you.) I think I've got the correct end of the stick, there's a really good BMJ book that can probably explain things better than me, or perhaps an Academic would care to step into the breach :-) It's important to note that the statement concerns itself with chd/cva MORTALITY only. I'm wondering if it means "no proof of effect" or "proof of no effect" (Very different things.) Notably, statins reduce "all cause" mortality, and I'm assuming, chd/cva MORBIDITY, which I guess is the ultimate bottom line.
Thanks for the questionning, it's good to shake around the grey matter.
As you correctly surmised, ginge, I am a true cynic. And somewhat of a therapeutic nihilist.
My concern on this issue is that, faced with potential cost savings by encouraging widening use of statins, the boffins will tend to cherry-pick the statistics to support their agenda. That's why I am skeptical of our current love of meta-analysis. Mr. Dung quite accurately picked up on the deficiency in the mortality question.
And, as we've often pointed out, mortality still remains at 100%.
Saw my doc who looked at my records [over the last ten years my cholesterol level has been in the lower half of acceptable levels and as I have atrial fibrillation and can no longer fly [bugger!] and am taking a series of drugs to help the AF he has stopped the statin intake.
And that good mate of mine, diagnosed with Diabetes type 2, prescribed statins wound up in dreadful pain (lower lumbar region), pissing tar coloured urine ,investigated for all sorts of other things like kidneystones, took action himself & threw the damned medication down the toilet. He has never felt better, looked better & has little to recommend the medical profession. Oh, he once worked as a Medical Sales Rep & knows the inducements offered to GP's by the pharmaceutical giants. we have to suffer this lot every six months & they have the power to wrongfully diagnose, wrongfully prescribe dangerous drugs & potentially wreck the professional careers of pilots. For my other mate, having passed his Class One Medical (enhanced requirement as he was over the age of 60), wound up in ICU with double kidney failure just weeks later. Oh, he died.