Kristen Sparrow • February 08, 2023
I admire Dr. Redberg very much. She speaks truth to the “powers that be” pushing medications and imaging technologies and scantily researched medical interventions. (If you click on the photo it will take you to a great discussion on a podcast by ZDoggMD entitled “When Less is More in Health Care”). I’ve linked to her here and here.
As UCSF Professor Dr. Rita Redberg says about statins,
When assessing the potential harms of statins, it is prudent to keep in mind that although the purported benefits of statins will accrue to a few patients in the future, everyone prescribed a moderate-intensity statin is at risk immediately for the harms. Consideration of adverse effects is especially important for a primary prevention drug, which is prescribed to healthy people who feel perfectly well.
Habib AR, Katz MH, Redberg RF. Statins for Primary Cardiovascular Disease Prevention: Time to Curb Our Enthusiasm. JAMA Intern Med. 2022;182(10):1021–1024. doi:10.1001/jamainternmed.2022.3204
Although elevated low-density lipoprotein (LDL) is associated with higher rates of CVD,2 there is uncertainty regarding the net benefit to risk ratio of using statins to reduce LDL among persons without CVD (primary prevention). This contrasts with the established role of LDL reduction for persons with established CVD (secondary prevention).
Although the USPSTF analysis6 did not find a statistically significant increase in incident diabetes, a prior meta-analysis of 13 trials (n = 91 140) found that 1 extra case of diabetes per 255 patients over 4 years of statin treatment could be attributed to statin use.21 Furthermore, individuals with other risk factors for glycemic intolerance and people with preexisting diabetes are likely to be at increased risk of progression to diabetes22 and worsened glycemic control, respectively.23 When assessing the potential harms of statins, it is prudent to keep in mind that although the purported benefits of statins will accrue to a few patients in the future, everyone prescribed a moderate-intensity statin is at risk immediately for the harms. Consideration of adverse effects is especially important for a primary prevention drug, which is prescribed to healthy people who feel perfectly well.
The practice of medicine is an art as well as a science. As the USPSTF and other professional societies, including the American College of Cardiology/American Heart Association24 and the European Society of Cardiology/European Atherosclerosis Society14 have all emphasized, shared decision-making of the anticipated benefits, harms, and uncertainties in predicting CVD are essential in determining whether to initiate a medication that a patient may possibly take for the remainder of their life. Although there are patient-facing decision-support aids for statins,25 they are underused. These aids would be more useful if quality-of-life data were collected in statin trials and could be added to decision-making tools. In addition, consideration should be given to deprescribing statins for adults 76 years or older, other older individuals unlikely to derive benefit from statins for primary prevention, and individuals who are at risk of polypharmacy because of medications taken for other conditions.
In the US, about $25 billion is spent annually on statins.26 Cardiovascular disease incidence and mortality are the upshot of myriad social determinants.27,28 Although statins lower LDL cholesterol in individuals, investments at the community level to construct a more salubrious environment that enables healthy eating and promotes physical activity are likely to have more widespread multiplicative and pleiotropic effects on the biological and psychosocial risks of CVD, as well as on improving quality of life. The 2022 USPSTF recommendations5 are an opportunity to pause and refocus efforts to meaningfully improve CVD outcomes for all, rather than extol the marginal, likely small, and uncertain absolute benefits of statins for the few in primary CVD prevention.