"Are Doctors Misleading Patients About Statin Risks and Benefits?"
Drug companies go out of their way, for example in direct-to-consumer ads,
to present drugs as the preferred solution to cholesterol management
while downplaying lifestyle change. You see this echoed
in the medical literature. Despite decades of exhortation for improvement —
this editorial in the "Journal of the American Medical Association" read—
the high prevalence of poor lifestyle behaviors persists, with heart attacks
and strokes remaining the leading causes of death in the United States.
Clearly, we need to put more people on drugs.
A reply was published in the "British Medical Journal."
Once again, doctors are implored to "get real" --- stop hoping that efforts
to help their patients and communities adopt healthy lifestyle habits
will succeed, and start prescribing more statins.
Don't you see how this is a self-fulfilling prophecy?
I should note that the author of the pro-statin editorial disclosed funding
from 11 different drug companies,
which make billions of dollars of cholesterol-lowering drugs.
Every time the cholesterol guidelines expand the number of people eligible
for statins, they're decried as a "big kiss to big pharma,"
understandably since the majority of guideline panel members
may have financial conflicts of interest.
But these days all the major statins are off patent, so there are inexpensive
generic versions. For example, the safest, most effective statin
is generic Lipitor, sold as atorvastatin, for as little as a few bucks a month,
so these days the cholesterol guidelines are not necessarily
part of some industry plot.
It's the American way of life that's the problem, not the guidelines.
The reason so many people are candidates for cholesterol and
blood pressure lowering medications is because people are taking
such terrible care of themselves. The bottom line is that individuals
must take more responsibility for their own health behaviors.
But if you're unwilling or unable to improve your diet and make
lifestyle changes to bring down that risk, if your 10-year risk of having
a heart attack is 7.5% or more and going to stay that way,
then the benefits of taking a statin drug likely outweigh the risk.
But that's really for you to decide. It's your body, your choice.
Whether or not the overall balance of benefit and harm justifies the use
of a medication for an individual patient cannot be determined by
a guidelines committee, a health care system, or even your physician.
Instead, it is the individual patient who has a fundamental right to decide
whether or not taking a drug is worthwhile.
This was recognized by some of medicine's luminaries,
but only recently has the medical profession shifted from
a paternalistic "doctor knows best" stance, towards one explicitly endorsing
patient-centered, evidence-based, shared decision making.
One of the problems with communicating statin evidence to support this shared
decision making is that most doctors have a poor understanding
of concepts of risk, probability, statistics.
But that understanding is critical for preventive medicine.
When doctors offer a cholesterol-lowering drug,
they're doing something quite different from treating a patient who is sick.
They're almost like life insurance salespeople, peddling deferred benefits
in exchange for an ongoing cost. In this new kind of medicine,
not understanding risk is the equivalent of not knowing about basic anatomy.
So, let's dive in and see exactly what's at stake. When drug companies say
a statin reduces the risk of a heart attack by 36%, that's what's called
the relative risk. If you follow this asterisk here, you can see
how they came up with that. In a large clinical study, 3% of patients
not taking the statin drug had a heart attack within a certain amount of time,
compared to 2% taking the drug.
So the drug dropped heart attack risk from about 3% to 2%.
That's about a one-third drop, hence the 36% reduced relative risk statistic.
But another way to look at 3% to 2% is the absolute risk
only dropped by 1%. So in effect, your chance of avoiding a heart attack
over the next few years is about 97% without treatment,
but you can increase it to about 98% by taking a statin every day.
Another way to say that is that you'd have to treat 100 people with the drug
to prevent a single heart attack. That statistic may shock a lot of people.
If you ask patients what they were led to believe, they don't think
the chance of avoiding a heart attack within a few years
on statins is 1 in a 100, but 1 in 2.
On average, it was believed that most patients would be able to avert
a heart attack, not just 1% of patients. And this disparity between the actual
benefits and expected benefits could be viewed as a doctor's dilemma.
On the one hand, it's not ethically acceptable for care givers to
deliberately mislead people into thinking a drug works better than it really does.
But on the other hand, how else are we going to get people to take their pills?
If you ask people, they want an absolute risk reduction of at least about 30%
to take a cholesterol-lowering drug every day,
whereas the actual absolute risk reduction is really only about 1%.
So the dirty little secret is, if patients knew the truth how little these drugs
actually worked, almost no one would agree to take them.
So either doctors are just not educating their patients,
or they're actively misinforming them.
Given that the majority of patients expect a much larger benefit
than they'd actually be getting, there is a tension between the patient's right
to know and the likely reduction in willingness to take the drugs
if they discovered the truth. This sounds terribly paternalistic,
but hundreds of thousands of lives may be at stake.
If patients were fully informed, people would die.
About 20 million Americans are on statins. Even if they saved 1 in 100,
that could mean hundreds of thousands of lives lost if everyone stopped
taking their statins. It's ironic that informing patients about statins
would increase the very outcomes they were designed to prevent.