If any preventative drug use had good evidence supporting it, you’d think cholesterol-lowering statins would. They are given out to around five million healthy people in the UK with the aim of lowering their risk of having a heart attack. For fifteen years or more there have been hundreds of large-scale double-blind, evidence-based-medicine gold-standard trials testing them. If you can’t nail down the whether taking statins is worth it or not, can we ever say anything for definite about any drug?
But as a debate in this week’s JAMA (Journal of the American Medical Association) shows it is still possible for two senior scientists to disagree strongly over whether they are worth taking if you are healthy and haven’t had a heart attack. (This isn’t about their value if you do have heart disease.)
So of course I was cheering along with the No (don’t take them) side. I can tick off the points: large numbers have to take them for one person to benefit, the side effects have been massively downplayed, a big recent review by the Cochrane Collaboration highlighted the small benefit and criticised the lack of good reasearch into side effects, even though we are within a year of the last of them coming off patent so it will never be done. Something else that is outrageous
One noticeable feature of the debate was that both sides drew on different sources. I was familiar with most of those mentioned by the No side and could criticise the opposition on some points, such as using studies to prove the drugs were effective that largely involved people who already had heart disease. But there were some studies I was unfamiliar with – like one showing women benefited – and I confess I’m not going to track it down and see if I agree with the conclusion.
The point is that if you are one of the five million taking the drugs or thinking about it, and quite reasonably you don’t intend to spend hours a week mugging up on statin trials, (let alone doing the same for other widely dispensed prevention drugs like aspirin) how can you ever make any sort of informed judgement?
Of course in theory that is the job of your doctor and beyond him various panels or boards who draw up guidelines. But this is where a whole host of other issues about trust and reliability start to kick in. Most of the doctor’s further education is paid for by drug companies. The majority of members of one of the boards that recommended lowering the cholesterol – dramatically increasing the number of people who would be eligible – received regular funds from the companies making the drugs.
Until we have a regulatory system that is far more transparent, relying on the drugs as the first step for prevention doesn’t seem very rational.