The great statins debate


On both sides of the Atlantic health issues continue to be hot topics.  On any given subject there are many divergent views and this is particularly the case with cholesterol and the use of statins.

In the USA it has already been proposed that statin usage should be broadened. Here in the UK  The National Institute for Health and Care Excellence (NICE) are proposing the same.

This contrasts with other experts who argue against increasing the use of statins. One such expert is the leading UK cardiologist Dr Aseem Malhotra who has been in the news recently.

Welcome to the  great statins debate!

The health arena is a political hot potato. Fraught with contention and controversy. For all parties - patients, GPs and especially the pharmaceutical giants - there's much at stake. If you're not currently taking statins and you're  a woman over 50 -  even if you're well -  you may fall into the new "at risk" category.

So what's going on here?

Firstly, lets look at what statins are and why they are prescribed.

In the UK  doctors currently prescribe statins to the following people -
  • Those with a history of Coronary Heart Disease
  • Those with a faulty inherited gene which causes an abnormally high cholesterol level - known as familial hypercholesterolaemia
  • Those with a 20% increased risk of developing heart disease  - based on a calculation that takes into account  factors like age, sex, BMI, ethnicity, cholesterol level, family history.

And it is this third group which is subject of much debate.

A recent BBC news report has indicated that  NICE are proposing to lower this risk to 10 %. Dr Malhotra  argues that this  would mean that some 12 million - otherwise mainly well people  - would have to take medication for life; with all the possible risks and side effects that this presents. The new controversy.

So what are statins and why the controversy?

Statins are a group of drugs prescribed to lower cholesterol levels in the blood. In the UK there are 7 million people on statins. Whilst in the USA 1:4 Americans over 45 are taking statins. The established medical view is that a build up of LDL cholesterol (the so called "bad cholesterol") causes hardening and narrowing of the arteries, which  increases the risk of heart attacks and stroke.

In the UK supporters of statins state that  statin usage has prevented some  7,000 deaths  a year. Statins and medication for lowering blood pressure has, they argue,  delayed the onset of cardiovascular disease by 20 years; resulting in some  20 more years healthy life for millions of people. Add to that figure those who are saved from other disabling but non fatal attacks, then it's clear why statins  have become the single most prescribed medication in the UK.

However, on the other side of the statins debate, the impartiality of industry led statistics has been challenged. The role of statins in heart disease prevention has also been  called into question. Dr Malhotra believes that the fall in rates of  heart disease has been more due to decreases in smoking and improvements to interventions in A&E. Opponents of broadening statin usage argue that the emphasis should be on tackling obesity and other lifestyle issues before turning us into a nation of "pill poppers". (On the diet question for a bit of light relief there's some interesting research into the benefits of eating an apple a day!)

The other area of controversy concerns the possible risks and side effects.

NHS choices states that statins are well tolerated, with most people not experiencing any side effects. However, there are many dissenting views and some experts have argued that the risks and side effects can be significant and can include an increased risk  in developing -
  • Cancer - which increases with age 
  • Diabetes - particularly in post menopausal women
  • Insulin resistance in non Diabetics
  • Cataracts - particularly in women
  • Pancreatitis and liver problems
  • Muscle pain
  • Nausea and vomiting
Ok, so we have all the arguements. The problem is what to make of it all.

About 20 years ago I ran a cholesterol screening service. Statins were only just coming in and only those with existing heart disease or hypercholesterolaemia were prescribed them. I call into question well people taking statins based on a quasi scientific risk calculation.  Dr Malhotra's view is that, although statins lower cholesterol, real-world data shows that they have "no effect on either overall death rates or rates of serious illness". His view is that by relying on medication we are sending out the wrong public health message ie pop a pill then, although you're obese,  at least you're less likely to have a heart attack or stroke. Rather we should be addressing the pressing obesity problem head-on. Which is where I want to see the debate focused.

The UK has already been called the statin capital of Europe. A recent report has also highlighted that we have one of the worse diets in Europe. For me there are also significant health issues of concern to older women taking statins.

Taking a broader view the health and fitness message for the older woman seems to be more about what you eat, your relationship with food, whether you exercise and  how you sleep. Hopefully, over the coming months we'll see the debate broadening  out beyond the statins frontier. 

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