SECOND OPINION: Should statins be routinely prescribed to patients with high cholesterol?
FEATURE - 16TH NOVEMBER 2016
As doctors, we look at something called 'numbers needed to treat' - that is, how many people you would need to give a medicine to in order to prevent one negative event. In this case, how many people would need to take a statin every day for five years in order to prevent one heart attack or stroke?
Statins are very effective at reducing your cholesterol and they will do this very well for the majority of people. However, my feeling is that they should not be routinely prescribed to someone who presents with high cholesterol.
Split the population in two: people who have had a cardiac event such as heart attack or stroke, and people who haven’t. For the first group, you are trying to prevent another event, and for them there is pretty robust evidence that prescribing statins is an excellent treatment.
But for everybody else—the majority of the population—you are trying to stop the event in the first place. For those people, lots of research is being directed at how effective statins are at reducing the risk of a heart attack or stroke. Currently, the evidence isn’t conclusive.
As doctors, we look at something called ‘numbers needed to treat’—that is, how many people you would need to give a medicine to in order to prevent one negative event. In this case, how many people would need to take a statin every day for five years in order to prevent one heart attack or stroke? At the moment it is about 60 or 70 people which is a relatively high number to prevent that one person having a cardiac event.
No medication is without side-effects, and with statins, these sit in a spectrum from muscle aches to actual muscle breakdown. Muscle breakdown is extremely rare, but muscle aches are more common. The issue is complicated by something called the ‘nocebo’ effect. This is when you inform a patient of the potential side-effects and they go on to develop them through psychological mechanisms rather than chemical ones.
As a doctor you are duty bound to notify patients of potential side-effects and if a patient tells you they are suffering, you have to treat it as a reaction to the medication. This is just another reason to avoid prescribing statins if you don’t have to.
So taking the ‘numbers needed to treat’ approach, statistically you are giving a great many people daily medication with potential side-effects, all to prevent a single outcome. And who is to say whether that is a reasonable risk? Some people may decide it is, others may not.
There are lots of things you can do to reduce your cholesterol. The big one is giving up smoking. I would also suggest exercise. We are not talking about training for a marathon, just two to two and-a-half hours of light exercise, or 90 minutes of intense exercise, every week.
Changing your diet can also be effective: cutting down on processed sugars and eating more oily fish, which have beneficial effects on your cholesterol. Eating more fruit and vegetables each week—which I know from personal experience can be difficult to maintain over a long time—is well worth the effort.
Doing these things can have enough of an effect on cholesterol levels for some people not to need to go on medication. It is the ideal solution because not only is their cholesterol getting lower but their cardiovascular and general fitness improves, with all the benefits that brings.
Dr Laurence Gerlis
YES: everyone, whatever their cholesterol levels, should take statins after a certain age
I am a very strong believer in statins. In fact, I believe them to be one of the greatest medical advances of the 20th century. There has been a lot of debate about the side-effects of statins, with a possible link to diabetes and muscular problems. But while these questions must be investigated, we should not abandon the drug.
My wife’s brother died of a heart attack at the age of 33 while playing football. He was active, very fit, a non-smoker. He only had one risk factor for heart disease: an inherited high cholesterol level. And it killed him, leaving a widow and three children. Had he been on statins, they would have dramatically reduced this risk. But while I admit there’s an emotional aspect to my stance, I believe it is backed up by the data.
Like any medication, I do not prescribe statins lightly. Cholesterol comes in two types: high density lipoprotein (HDL), which is good, and low density lipoprotein (LDL), which is bad, and the ratio between the two types is vital. HDL cholesterol is actually protective of the heart and some people naturally have high HDL levels, which causes their high cholesterol reading. If this is the case you don’t have to prescribe any medication.
Lifestyle choices also affect people’s cholesterol levels. You can reduce cholesterol with changes in diet, and sometimes this is enough. I also look at other risk factors for heart diseases: do they smoke, are they overweight, do they have diabetes or high blood pressure, and so on. If action is needed on any of these I will advise accordingly.
But if after about 10 weeks their LDL is still elevated, I will start a patient on statins, even if none of the other risk factors are a concern. I would also choose a high enough dose to have an effect as soon as possible. Once you start treatment, you should do so aggressively so that the patient starts to get the benefits as soon as possible, and then fine tune the dose later.
I would start them on one of the simpler ones like simvastatin, but if they developed side-effects I would try a different type. There are a wide variety of statins to choose from, so you should always be able to find one that works.
In fact, my belief in statins goes further: I believe that everyone, whatever their cholesterol levels, should take statins after a certain age. We have an ageing population with increasing cases of dementia. Most age-related dementia is actually caused by hardening of the arteries in the brain causing mini strokes which kill brain cells. This is linked to cholesterol, so statins could improve the lives of thousands of families. I would start thinking about this when people reached their mid-30s, before they start furring up their arteries.
I take statins myself. I am on my third different type because I suffered some unpleasant side-effects from the first two, so I am not pretending that they are a panacea. However, I believe they are a first class, life saving drug, and making the most of them would lead to huge public health benefits for the country as a whole.