Friday, May 18, 2012

Let's Put Statins in the Water!

Are you ready to put statins, those ubiquitous cholesterol lowering drugs, in the water yet?  In case you haven't swallowed the Kool-Aid, let's review what statins can do, at least if you have known heart disease: lowering your cholesterol with the use of statins can reduce your risk of vascular events, be they heart attacks or strokes.  The same cannot be said about other cholesterol lowering agents which can lower cholesterol, some impressively so, but they don't prevent events.  It's like whitewashing the fence.  You can make it look better but in the end, it still needs mending.  This much we can agree upon.

More recently, the Food & Drug Administration ordered statin manufacturers to revise labeling of their product to warn of a possible risk of hyperglycemia and cognitive dysfunction.  An editorialist in the New England Journal of Medicine put it this way last week: we don't know who's at risk of developing hyperglycemia as result of statins but it would appear to be those who were already at risk.  But even if a small fraction of the population developed hyperglycemia, it would make no sense to stop taking the statin because they're already indicated for treatment in those w/diabetes.  The question regarding loss of memory is a bit trickier although studies show that lowering cholesterol w/statins lowers stroke risk.

Given that prelude, consider the meta-analysis published early online yesterday in the Lancet in which 134,537 participants were followed for 4.8yrs in 22 trials of statin vs control resulting in a 39mg/dL difference and another 39,612 participants were followed for 5.1yrs in 5 trials of less vs more statin resulting in a 21mg/dL difference.  The authors concluded that in low risk individuals w/5yr risk of major vascular events (non-fatal myocardial infarction, coronary death, stroke and/or revascularization) <10%, each 39mg/dL reduction in LDL cholesterol lead to an absolute reduction in major vascular events of 11 per 1,000 patients treated for 5yrs.  Number needed to treat for the two lowest risk categories were 167 and 67, respectively, similar to those for treating hypertension.  Most importantly, there was no increase rate of cancer incidence, cancer mortality, or other non-vascular mortality.

The point is that even in low risk patients, taking a statin can lower one's risk for major vascular events to a greater degree than risking diabetes and memory impairment.  So, are we ready to put statins in the water?  And by the way, in case you were wondering, putting statins in the water to prevent major vascular events in low risk patients would be considered primary prevention.

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