September 18, 2014

Bye-Bye to My Statins

I believe that "less is more." Back in April, I ditched my blood pressure pills. This weeks it's the statins I've been taking for decades to treat my elevated blood pressure. 

Here's what lead to that decision:

Are Statins Worth the Risk?
That question is increasingly being asked by doctors and medical authorities. Statins are one of the most commonly prescribed medications in the U.S. They are taken by an estimated 1 in 4 middle-aged adults.

They may become even more widely used. New cholesterol guidelines, introduced last November, could push that ratio to as many as 1 in 2 adults over age 40.

But for several years now there has been a simmering debate in medicine over statins."The prevailing dogma has been this statins are almost harmless and that they're a wonderful drug," says Tom Perry, MD, a pharmacologist and internist in Vancouver Canada. Caray is part of a team of doctors at the University of British Columbia that looks at the evidence for and against drugs.

A recent issue of their free bi-monthly, Therapeutics Letter, urged doctors to be more mindful of side effects when writing prescriptions for statins. Their review found statins decrease energy and fitness, increase fatigue and sleep problems. They also found that statins may increase the risk of muscle aches and pains, kidney and liver problems, bleeding in the brain, and type II diabetes.

"If people understood how relatively modest the benefits of statins are, they might be much more conservative about taking them, especially if they're experiencing an adverse effect, and we don't think the salesmanship has included an adequate emphasis on the importance of not harming people,"

Statins For Older Patients?
Should older adults take statins if they have elevated cholesterol but no evidence of heart disease?

This is the hottest issue in the statins debate.

Recently AMDA, a professional group representing physicians working in nursing homes, highlighted the issue in a list of five questionable medical tests and treatments. The list was drawn up as part of the national “Choosing Wisely”campaign, which alerts consumers to inappropriate or overused medical interventions.

The standout item on the AMDA list: “Don’t routinely prescribe lipid-lowering medications for individuals with a limited life expectancy.” That means anyone older than 70, according to the medical society.

Dr. Hosam Kamel,  an Arkansas geriatrician who is vice chair of AMDA’s clinical practice committee, said that there is scarce scientific evidence supporting the use of statins by 70- or 80- year -olds without pre-existing cardiovascular disease. Only a handful of studies have focused on outcomes (heart attacks, strokes, premature death) in this older population.

Most of the data on the benefits of statins use come from larger studies that looked at adults of varying ages. The results don’t conclusively establish the benefits of using statins for seniors with healthy hearts, Dr. Kamel said.

There is evidence of harm linked to statins use, including muscle aches, liver toxicity and gastrointestinal distress; growing evidence of impaired memory and a heightened risk of diabetes; and some evidence of an increased risk of cancer.

“Our recommendation is that physicians weigh the potential risks and benefits and not automatically prescribe this medication,” Dr. Kamel said. This advice applies only to seniors who haven’t been diagnosed with cardiovascular disease.A significant body of evidence does support the benefits of statins in older adults who have already had a heart attack or stroke.

Many leading cardiologists agree with the AMDA’s recommendation. Others support the emphasis on individualized decision-making. But some might, for example, give a statin to a healthy 80-year-old if the patient had a Framingham Risk Score of 20 percent or greater.                                                                                      
(This is a test to assess the risk of a heart attack. You can calculate your own Framingham Risk score here..)

An outspoken critic of statins is Armon Neal, a consulting pharmacist who has received the annual achievement award from the American Society of Consultant Pharmacists. Neel, together with Bill Hogan, are authors of the intriguing book,  Are Your Prescriptions Killing You?" The book has a chapter titled, "Statin Roulette."

If  you are over 60, Neel warns, "stay away from statins at all costs."  Not one to pull punches, Neel says:
I stop these drugs on all the older patients I see because they are invariably at the root of nearly all their problem.
I reported on the case against statins made in this book in a July 2012 post.

Experts agree that more high quality evidence is needed about statin use in seniors without existing heart disease. Pending that, this debate isn't going to be resolved any time soon.

My Decision To Stop the Statin Pills
Reviewing the literature, I found that some doctors agree with Neel that seniors should avoid statins at all costs. But many, while agreeing that statins are risky for seniors, still would prescribe them in certain cases, such as where an elderly patient, while still healthy, has a Framingham Risk Score of 20 percent or greater.

So last week I had my cholesterol checked at my local CVS Minute Clinic. Here are the results:
  • Total cholesterol - 150 (below 200 is the desirable target)
  • L(ousy)DL - 81 (target under 100) 
  • H(ealthy) - 60 (target between 40 and 60)
  • Triglycerides - 47 (target under 150) I was off the chart since the lowest number listed for scoring was 50)
(I appreciated the CVS nurse's giving me this memory aid, since I never could remember whether it was HDL or LDL that was the "good" cholesterol.)

I plugged the relevant  numbers into the Framingham score sheet and was told I had a 19 percent chance of having  a heart attack in the next ten years. That put me right on the cusp of the 20-percent score which many doctors use as the dividing line in deciding when to prescribe a statin for a healthy 80-year-old with no prior sign of heart disease.

But the Framingham score sheet only uses the numbers on total and HDL cholesterol.   I had even better scores when compared with the targets on LDL and triglycerides.

And "less is more!"

The decision: So long statins.

1 comment:

Lindsay Hilsenbeck said...

Thank you for your great article. I have long doubted the need for so many folks to be prescribed statins. And felt they are a pretty unpleasant drug all around. Scariest stats i have seen is how many really young children are now being given these drugs. My husband and I are now taking red yeast rice supplements - having talked to our friend who is a GP and treating his own cholesterol this way. So far so good...