Monday, November 25, 2013

New Cholesterol Guidelines, Part Two

When I first posted on these guidelines:
http://brodyhooked.blogspot.com/2013/11/new-cholesterol-guidelinesthe-devil-in.html
--I figured that others would soon chime in who understood the technical details much better than I did and who could therefore make clearer what the problems were.

One such contribution is now up on the Health Care Renewal blog, courtesy Dr. Roy Poses:
http://hcrenewal.blogspot.com/2013/11/confused-thinking-about-new-cholesterol.html

In a long post, Dr. Poses adds two important things to my earlier comments. First, he drills down a good deal into why the new risk calculator attached to the guidelines is flawed and premature. Second, courtesy the Pharmalot blog, he fills in more details about conflicts of interest among the guideline panelists, showing that I was too optimistic when I stated that COI was at least somewhat kept under control or at least acknowledged more. (For example, it’s nice, according to the IOM guidelines for writing good guidelines, that the chair of the panel had no financial ties to industry. But does it matter that in order to become guideline chair, he had to divest himself of a whole pile of financial ties that he previously enjoyed? Divestment: good; lots of things that needed to be divested:  perhaps not so good.)

Nevertheless, while more details are being filled in, it is still challenging to keep the big picture in view. The media accounts I’m seeing in the newspapers seem calculated to reassure patients that it only appears that the cardiology crowd is in disarray over the guidelines; actually everything is just fine, so if your doc says to take a statin, you should have full confidence that it’s good advice. In short, if the drug industry could have written the script, it would be saying what most people are now saying.

So to restore a sense of perspective, let me go back to a theme I have tried to raise on a number of occasions, for example:
http://brodyhooked.blogspot.com/2009/07/more-on-statins-new-bmj-meta-analysis.html

The old narrative, that has led to so many millions of Americans being placed on statin therapy, at great cost and at huge risk of serious side effects, is: if your bad cholesterol is high, you’re at greater risk for heart disease and stroke. Statins lower your bad cholesterol. So you need to go to the doc, get a blood test to check your cholesterol, and if it’s an eentsy bit high, start taking statins for the rest of your life.

If you carefully ask the right questions of the research that’s been done in recent years, you learn that there is a shrinking amount of evidence that supports this narrative, and a lot that says it’s in fact just plain wrong. To the extent that statins reduce your risk of future bad stuff, as they seem to, a little, in people with existing heart disease, there’s now many reasons to believe that they don’t do it by lowering cholesterol in the blood. The new guidelines, as I said in my previous post, sort-of-kind-of admit this by eliminating the need to check cholesterol levels routinely and the idea of target levels of cholesterol to shoot for.

So if the guidelines were true to the evidence, what message would emerge? The message would certainly be: the grounds on which we used to prescribe statins were all wet; there are a bunch of folks now taking statins who probably don’t need them; we need to be much more refined in selecting the smaller subsets of people who might actually benefit from taking statins.

What message is actually being disseminated? It seems to be: If you took statins under the old guidelines, have faith and keep taking them. If you were not on statins previously, don’t worry, because our new, flawed risk calculator will probably say that you too need to be on statins.

As I said, if the drug industry had been allowed to write the script for this, it would have said exactly the same thing.

1 comment:

Robert Gomez said...

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