Seize the day on statins

A LEADING cardiologist says GPs are still seeing patients planning to discontinue statin therapy after a controversial television program last year questioned the value of the drugs.

In an MJA Perspectives article, Professor Ian Hamilton-Craig, professor of internal medicine and preventive cardiology at Griffith University, Queensland, said despite rebuttals of the program in subsequent media reporting and by the National Heart Foundation of Australia (NHF), patients were still stopping their statins without medical advice. (1)

Professor Hamilton-Craig’s advice that ongoing public concern about statin therapy provided an opportunity for doctors to re-evaluate patients’ risk of cardiovascular disease (CVD) and ensure their treatment was in line with the current guidelines has been echoed by other experts.

Dr Rob Grenfell, the NHF national cardiovascular health director, said Professor Hamilton-Craig’s succinct summation of the real issues surrounding statin prescribing in Australia and advice to health professionals was “spot on”.

“Doctors need to take this opportunity to re-evaluate their patient’s absolute CVD risk and modify their statin therapy in accordance with the current National Vascular Disease Prevention Alliance guidelines”, Dr Grenfell said. (2)

He said for primary prevention of CVD, statin therapy was recommended for moderate risk patients (5-year CVD risk 10%–15%) if 3–6 months of lifestyle intervention did not reduce low-density lipoprotein cholesterol (LDL-C) levels or the overall absolute CVD risk score.

For all high-risk patients (5-year CVD risk greater than 15%), doctors should prescribe a statin straightaway to reduce their LDL-C level and overall risk score.

Dr Grenfell said the MJA article clearly demonstrated the low prevalence of side effects from statin use. “Rhabdomyolysis occurs rarely — one in one million statin prescriptions — myalgia in 10% of patients in clinical practice, and diabetes in 6% of patients who mostly have features of the metabolic syndrome”, he said.

In a recent systematic review of randomised controlled trials, UK researchers found that most side effects attributed to statin treatment occurred almost as frequently in patients taking a placebo. (3)

While they found an increased risk of new-onset diabetes in primary prevention trials, they determined that only one in five cases was caused by a statin.

Professor Anthony Keech, professor of medicine, cardiology and epidemiology at the University of Sydney and deputy director of the NHMRC Clinical Trials Centre, said statins were some of the most powerful drugs available to prevent mortality, and were “here to stay”.

“Doctors are working to explain to individual patients why it’s important that they don’t stop their statins. Generally speaking, decisions to start statins are very appropriate; if they’re not, all of this controversy triggers discussions between doctors and patients about why they’re on statins and whether they should remain on them”, he said.

Professor Keech, a member of the Cholesterol Treatment Trialists’ Collaboration, said while the recognition of side effects of statins had grown over the years, they remained small compared with the “very large” benefits of statin therapy.

He pointed to research his group published in 2010 that showed statins reduced the risk of mortality by 10% per 1 mmol/L reduction in LDL-C and reduced major vascular events by 20%–25% per 1 mmol/L reduction in LDL-C over 5 years. (4)

Professor Keech said the risk reduction was seen across patients from low to high CVD risk.

“At the end of the day, patients have to make up their own mind. We need to make sure that they do that with proper advice from their doctors who have the best information available — and we are making sure that that information is available [to them].”

In his MJA article Professor Hamilton-Craig also wrote that the long-term cost-effectiveness of statins remained a “major issue”.

“Although generic statins have cut costs in Australia by around 25%, they remain expensive by international standards. Lower costs may encourage changes to the PBS criteria, which would allow the use of statins for primary prevention of CVD in broader groups of patients as recommended in recent US guidelines.”

1. MJA 2014; 200: 440-441
2. Australian absolute cardiovascular disease risk calculator
3. Euro J Prev Cardiol 2014; Online 12 March
4. Lancet 2010; 376: 1670-1681