Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, May 21, 2009

Ahead of the Curve

Physicians are often castigated for not keeping up with and following the latest recommendations for clinical care. The reality of innumerable "guidelines" issued by countless specialty societies and other entities (cough*federal government*cough) that feel empowered to do so is that just keeping track of all of them can be a full time job. Still, there have been some major sea changes over the years as good science comes up with some pretty definitive findings. I'm referring specifically to broad brush guidelines about the treatment of that ubiquitous triad of high blood pressure, diabetes and LDL cholesterol.

Those of us who have been practicing for a few decades now recall that recommended goals for blood pressure, blood glucose, and lipid levels have tended to shift ever downwards over the years. When I was in training, the threshold definition for hypertension was a BP measurement of 140/90. Anything below that was fine; above it required treatment. Some of the older attendings even scoffed at that, recalling when an acceptable systolic blood pressure was "100 + age", a nod to the fact that blood pressure tends to increase with age, making isolated systolic hypertension common in the elderly. Diabetes outcomes seem to improve with lower blood glucose levels, and the advent of statin medications for lowering cholesterol has truly revolutionized lipid management. Further, growing evidence seems to support the lowering of all three parameters to decrease cardiovascular risk.

Now it seems that among patients with stroke and LDL levels already under 100 -- with or without statins -- those ON the statin lipid-lowering meds had better oucomes. Current guidelines for use of these drugs takes into account how many cardiovascular risk factors a patient has aside from the cholesterol reading. The greater the number of risk factors, the lower the threshold for starting cholesterol meds. Here's the thing: those numbers have also been trending downwards as the accumulating research points towards better outcomes for patients who take statins.

Here's where I'm going with this: whether or not to offer statins to non-diabetic non-smoking patients with controlled hypertension and moderately elevated LDL cholesterol levels.

According to current formal recommendations, a patient like that would not qualify for statins unless the LDL was over 160. At this time, that is. Every time those guidelines have been revised, it's been in the direction of starting statins at lower and lower levels of LDL. What if 10 years from now we have the data to support lowering LDL cholesterol to at least 130 in everyone? What if it turns out that taking a statin confers added protection against macrovascular events (stroke and heart attack) whatever level of LDL reduction is achieved (ie, goal or no goal)?

It sure looks like this is the way things are headed to me, and I would like my patients to have the benefit of an extra 10 years -- or however long it is until the jury returns -- of cardiovascular protection. Statins are now cheap ($40.00 a year) and extremely well-tolerated, with very rare adverse reactions that are easily reversed with stopping the drug. There just doesn't seem to be much of a downside to wider statin use, and the distinct possibility of a significant advantage.

Believe me, I am not a pill pusher. The more favorable evidence that accumulates for the damn statins, the more pissed off I get. The last thing I want is to be writing more drugs. Still, it's getting harder to deny my patients the benefits implied by the old "better living through chemistry" line.

The bottom line is that I have gingerly begun offering cholesterol-lowering meds to more of my patients, complete with extensive counseling and discussion (much like that above.) I'm curious about what other clinicians are doing, and how they feel about trying to get ahead of the curve a bit with primary prevention of cardiovascular disease.


At Thu May 21, 05:08:00 PM, Blogger Eric, AKA The Pragmatic Caregiver said...

Here's my one uncertainty about long-term statins in the "relatively healthy". Statins reduce production of CoQ10, which seems to act as a ubiquitous antioxidant and is an essential part of the electron transport chain in the mitochondria. With the rise of ever-more-effective HMG-CoA inhibitors, we're more and more effective at inhibiting isoprenation, which is awesome if we're talking about inflammatory pathways, but perhaps is low-awesomeness when we're talking about the energy pathway in every cell. See also Baycol.

High-quality CoQ10 supplementation that restores blood levels to pre-statin numbers is comparatively expensive - on the order of $500/year at the low end.

Thus, personally, I'm unconvinced that a statin is the right choice for me as a normotensive obese guy in his 30s with dyslipidemia.

At Thu May 21, 05:16:00 PM, Anonymous Anonymous said...

I think it's very important that you consider the NNT and discuss it with patients. Given the unfavorable NNT for statins in low risk people, I personally wouldn't start them. There was an article regarding the alleged "statin brain" phenomenon I read some time ago; in any event, the risk of poorly characterized/subtle side effects makes it a dodgy proposition in my mind.

At Fri May 22, 02:29:00 PM, Anonymous Anonymous said...

I don't give a dayum about the NNT!!!, if it's my Momma it can be 6 friggin billion and she's gettin it...
Only thing thats concerned me about the statins is that link between Low Cholesterol and increased Cancer rates..
And I take one myself, even with a non treated LDL of 90...
Just hope we don't find out they cause ALS or something...


At Fri May 22, 04:09:00 PM, Anonymous Lars said...

Frank, I personally think the NNT is quite important. With a low NNT, you may find it a lot easier to convince your patients that it's really necessary to take a certain drug. However, in the case of an unfavourable NNT, you burden your patients with daily medication, even though it's quite probable that they will never really benefit from it. The cost-benefit ratio might be a bit off for low-risk people.

Furthermore, when patients don't notice a direct effect (as for statins, antihypertensives, etc.), compliance is a major issue.

I'm still in med school though, so feel free to correct me ;)

At Sat May 23, 08:42:00 PM, Anonymous Anonymous said...

NNT right now does not support their use in low risk people.

I think Dino would admit that, but thinks further research will eventually show better NNTs (as that has been the trend, per dino).

So get ahead of the curve and anticipate the data. I personally don't agree, the data could go the other way too, or some rare but important side effect could eventually show up in the numbers (hormone replacement? vioxx?)

the data is the data. Data can be surprising. the past may not predict the future.

At Sun May 24, 11:24:00 AM, Blogger Steven Horvitz, D.O. said...


Let us look at this a different way.

You are at a charity ball spoonsored by Pfizer, maker of Lipitor. All 100 attendees paid $80 and get a ticket that will be placed into a raffle. The prize being protection from a potential vascular event in the future. But by being at this charity ball, you have a higher risk of myalgias, memory loss, liver injury, etc. You can attend this ball every month if you choose, along with 99 other people.

Do you go the ball?

BTW, proceeds from the ball go to Pfizer profits.

At Sun May 24, 11:35:00 PM, Anonymous cathyf said...

Odd, but everyone I know who has ever taken statins has either stopped taking them because of muscle weakness, or should because they are significantly disabled by the muscle weakness. Ah, well, I suppose that's anecdotal evidence...


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