Saturday, April 10, 2010

Forget the Science; Docs Already Know the Answers

Thanks to a faithful follower, I was clued into the program on Minnesota Public Radio last week:
The Midmorning program addressed the recent decision of the FDA to allow a relabeling of rosuvistatin (Crestor) based on the JUPITER trial, about which I blogged several times, such as:
Midmorning had two guests familiar to regular readers of this blog: cardiologist Dr. Steve Nissen of Cleveland Clinic, and family physician Dr. John Abramson. Both are usually known as critics of the pharmaceutical industry. In this instance they took mostly opposing views, Nissen defending the JUPITER results while Abransom took a more skeptical view (with which the bulk of the opinions I blogged about would agree; see

Two comments on the program. While the listeners heard pro and con views regarding the reliability of JUPITER, they did not hear much about what I consider the major news from that trial, which is to knock a further hole in the lipid hypothesis for heart disease, that claims that statins prevent heart disease primarily by lowering cholesterol and that regular cholesterol testing is a critical part of good preventive medicine.

The second comment is perhaps the more important, and includes the only mention that I heard of the challenge to the lipid hypothesis (though neither Abramson nor Nissen picked upon it). During the call-in part of the program, a family physician from Marshall, MN, "Vince," offered a different perspective which he presented as representative of all of the family docs he knew. He said that all of them, on reaching age 50, if they had the slightest hint of a risk factor for heart disease, immediately put themselves on cheap generic simvastatin. Vince agreed with those who believe that the lipid hypothesis has been largely disproved, and was quite willing to say that 1) statins probably work more due to their anti-inflammatory effects and not due to cholesterol lowering effects; and 2) therefore, checking cholesterol levels with repeated lab tests is pointless. But Vince also said that he and all his colleagues were completely convinced that statins were effective for primary prevention of heart disease, they hardly ever saw any serious side efects with statins, and now with generic prices they were dirt-cheap, so why not take one?

My own point of view is that "Vince" represents a fascinating partial victory of pharmaceutical marketing over science. (Both Nissen and Abramson agreed to disagree with Vince.) He's right, I think, in debunking the lipid hypothesis. But I think his confidence that statins are so wonderful for primary prevention reflects the huge success of Pharma brainwashing (see my last post on JUPITER-related stuff, It's one of those many features of today's medicine that future medical historians will look back on and shake their heads over.


Anonymous said...

I would say it is also a demonstration that many doctors have either lost the ability to think logically, or did not develop that skill in training.

Marilyn Mann said...

I listened twice, and my take on what Vince was saying is slightly different. He said he was convinced that statins have anti-inflammatory effects. I didn't hear him say that their benefits were solely due to those effects. With respect to lipids, he was a little unclear, but I thought he was saying that statins benefit people who are at cardiovascular risk, regardless of their baseline LDL. The part that was unclear to me was where he said something about not needing to check LDL levels. If he means not ever checking LDL, even for determining baseline risk, I would disagree with that. It is clear that LDL levels help in estimating risk. If he means that once you have determined baseline risk you do not need to keep checking LDL levels to see if you have reached a particular target, that view has been advocated by a few others, notably Rod Hayward. In any case, I agree with you that putting everyone on statins when they reach age 50 (or perhaps he was only referring to his male colleagues?) is too aggressive. It wasn't clear to me if he does that for his patients as well. Hard to get an accurate sense of a person's position based on a brief call-in to a radio program.

I agree with Dr. Nissen that one has to be very careful in using aspirin for primary prevention. A recent meta-analysis showed that the benefit for CHD was very small. There really isn't good enough data to say whether aspirin should be prescribed for everyone whose risk is over 10 percent. Aspirin increases the risk of bleeding, including serious and even fatal bleeding, so should only be used when the benefits outweigh the risks. In fact, aspirin is more hazardous than statins. Statins can have side effects, but the overwhelming majority of them are relatively minor, such as muscle pain.

My view on primary prevention is that each person's baseline risk should be estimated. Then they should discuss with their physician whether the risk reduction that can be achieved with a statin is worthwhile to them, bearing in mind the risk of side effects, the cost, and the inconvenience of taking a pill every day. As Dr. Nissen points out, the cost varies a lot depending on whether the statin is generic or not.

Your readers might be interested in listening to Dr. Gordon Guyatt discussing the JUPITER trial:

Paul Scott said...

I wrote about the possibility that statins create their small beneficial reduction in risk due to anti-nflammatory properties, in an article on Ronald Krauss and small LDL in a recent issue of Men's Heath. Krauss feels the two are additive, but he also believes that large LDL, which is largely benign, so markedly throws off a standard LDL count as to make it a sloppy instrument for assessing risk. He supports the counting of small LDL (and, caveat here, owns systems that do as much) but his science has been on this track for 30 years.