Sunday, November 24, 2013

Statins - what to do, what to do

The following is a letter I just sent off to my doctor:

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Thank you for acting so quickly to get the atorvastatin to me by mail.  It arrived yesterday and I took my first 20 mg. pill.

I have decided, however, not to take any more until or unless I have built up greater confidence that statins are a good idea.

After resisting advice to take statins for some years now, I made the decision to go ahead with a statin regimen after hearing that the American Heart Association and the American College of Cardiology had put out new guidelines suggesting that because of my age and risk profile, statins were highly recommended.

My understanding is that you are working at Kaiser with guidelines that have been in place since 2001.  According to these guidelines, my triglyceride level should be under 199mg/dL (as of last August, it was at 98), my HDL level should be 40 or greater (it is at 38) and my LDL level should be 129 or lower (it is at 144).  Furthermore, according to the risk calculator you have been using, statins are advisable for someone my age when the risk of heart attack goes over 20%.  My risk level is calculated at 22%.  Elsewhere I see the cutoff level at as low as 7.5%. 

Because of the potential side effects of statins, which I understand to be “muscle pain and muscle damage; an increased risk of diabetes; memory loss and confusion; cataracts; and, to a lesser degree, kidney or liver damage,” and because of an inclination to want to avoid drugs on general principles, I have resisted taking your advice, with considerable misgivings.

Then the new AHA and ACC guidelines came out, and I relented and began taking the atorvastatin yesterday.

But no sooner do I do this, than I begin to hear reports from people who appear to be in the know that these new guidelines are a bad idea.

1) An article in the Boston Globe claims the new guidelines are a mistake for two reasons.  They suggest we should ignore LDL levels in favor of a risk calculator, but then it turns out the risk calculator overestimates risk by up to 150%.   That would bring my risk level below 20%, and if the LDL level is not a useful number, (except for people who have already had a heart attack – which does not include me) there go the reasons for starting the statin regimen.

2) In the Globe and Mail of Toronto, health reporter André Picard confirms the information in the Boston Globe.   Picard reports on a study published in the British Medical Journal arguing just the opposite of the new American guidelines, namely that “statins have no overall health benefit in this population and that prescribing guidelines should not be broadened.”  

3) An editorial in the New York Times expresses reservations even more starkly:

Patients in good cardiovascular health would be well advised to stay away for now from following the cholesterol guidelines issued last week by the nation’s two leading heart organizations.  

I will keep the medication (it has a discard date of 21 May 2016) until the heart organizations reassess their risk calculator, and provide me with greater motivation for going back to the statin regimen.

Please, by all means, let me know if you see flaws in my thinking.  I could do with a whole lot more information and am keeping an open mind on the question.

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Remember the days when the doctor gave you advice and you simply took it, no ifs, ands or buts?

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