Jul 24 2012
Red Yeast Rice and Cholesterol
While much of CAM is ridiculous or implausible, herbal remedies are an exception. Plants produce pharmacologically active substances; in fact, the science of pharmacology grew out of herbalism. Some herbal remedies have not been scientifically tested, but others have been tested and are clearly effective. Nevertheless, these are seldom if ever the best choice for treatment.
One natural remedy stands out. Red yeast rice has been tested and has been shown to lower cholesterol as well as a statin drug. That’s hardly surprising when you realize that it contains the exact same ingredient as the pharmaceutical drug lovastatin.
Only it doesn’t any more.
Origin
Red yeast rice has been widely used in Asian cuisines as a coloring agent and taste enhancer. It has been used in traditional Chinese medicine for centuries for indigestion, diarrhea, blood circulation, and spleen and stomach health.
Preparation
It is prepared by fermenting rice with the yeast Monascus purpureus. It contains eight mevinic acids (statins), mainly lovastatin or monacolin K. It also contains sterols and other components. Its overall cholesterol-lowering effect may be due to a combination of several of its constituents. In manufacturing it for use as a supplement, temperature and growing conditions are carefully controlled to increase the concentration of mevinic acids. These products are not the same as the red yeast rice sold in Chinese grocery stores.
Safety concerns
The safety of red yeast rice has not been established. The Natural Medicines Comprehensive Database only gives it a “possibly safe” rating. Since it contains lovastatin, it can be expected to have the same side effects as the prescription drug. Patients on statins are monitored for liver, muscle, and kidney damage; sellers of red yeast rice do not usually inform their customers of those risks. There are also a number of interactions with other drugs and dietary supplements. And eating grapefruit can affect blood levels of lovastatin.
Regulatory actions
When does a food cross the line to become a drug? Red yeast rice was marketed in the US as a dietary supplement, Cholestin. The FDA banned it in 1998, saying that since it contained lovastatin it was an unapproved drug. In 1999, a federal judge overruled the FDA, saying it could be sold as a food supplement. In 2000 a Circuit Court of Appeals said that ruling was in error and restored the FDA’s ability to regulate Cholestin as a drug. The FDA then sent warning letters to several companies, and the product disappeared from the market for a few years.
The manufacturers’ response
Red yeast rice products gradually reappeared on the market. Around 30 brands are now available. Most of them got around the FDA restriction by eliminating the monacolin content and by careful labeling and advertising that does not claim to lower cholesterol. In 2007, the FDA sent warning letters to two companies whose products still contained monacolins; the products were withdrawn. Red yeast rice products are still widely sold in the US and products containing lovastatin are still readily available from other countries.
Pharmanex continues to sell a product under the name Cholestin, but it no longer contains lovastatin. They say:
Cholestin® is a breakthrough all-natural solution for individuals concerned with maintaining cholesterol levels already in the normal range.
Cholestin’s proprietary blend contains polymethoxylated flavones extracted from citrus fruits, geraniol and the essential fatty acids EPA and DHA found in marine lipids. Each individual constituent has been shown to control existing normal cholesterol levels in the body and promote overall cardiovascular health. Only Pharmanex’s new Cholestin® offers this unique blend of scientifically-tested constituents for effective cholesterol management.
Pharmanex sells Cholestin for around a dollar a pill. Theprice of lovastatin varies from 29 cents to $1.71 per pill
CAM recommendations
Dr. Andrew Weil recommends red rice yeast extracts, saying they are by far the most effective natural supplement for lowering cholesterol and claiming that they are less likely to cause side effects than prescription statins.
Dr. Oz says red yeast rice is a statin that will lower your cholesterol by 30 points.
Dr. Mercola says red yeast rice is a statin and all statins should be avoided.
Natural News recommends it but notes that supplements currently sold in the US don’t contain any of the active ingredient.
Many websites have outdated and false information.
Other herbal remedies
My general objections to herbal medicines are these:
- When tested, isolated active ingredients tend to work at least as well as the whole plant derivative.
- Although herbalists claim that the other components in their remedies act synergistically, that has seldom been substantiated, and the other ingredients might just as well be expected to do harm or to decrease the effect of the active ingredient.
- Most herbal products have not been adequately tested to ensure safety.
- Herbal products on the market vary in dosage and purity. There is no guarantee that you will get what the label says.
- Products may contain contaminants. Products have been found to contain everything from toxins to insect parts and even prescription drugs.
I see no good reason to prefer St. John’s wort to a prescription antidepressant. On a practical basis, I can understand that some people might prefer it because it is less expensive and can be acquired without a visit to a doctor with all the inconvenience and cost that entails. But I think their health would be better served by being diagnosed and regularly monitored by a medical doctor and by taking a pure antidepressant in a controlled dosage.
Conclusion
Red yeast rice containing lovastatin is effective in lowering cholesterol, but brands currently sold in the US contain no lovastatin. It’s ironic that one of the few proven CAM treatments was effective only because it contained a drug available by prescription. And that they continue to recommend it after the lovastatin was removed. Even if a lovastatin-containing red yeast product can be obtained, concerns remain about purity and safety. It would be hard to justify recommending it over a pharmaceutical statin.
176 Responses to “Red Yeast Rice and Cholesterol”
Consumer Lab tested several brands of red yeast products sold in the United States in 2011. Some contained lovastatin in significant amounts. Some didn’t. Some companies are following the law and producing supplements that are legal but worthless. Others are violating the law and producing supplements that are illegal but effective.
You have to pay to get their report, but it might be worth it.
The same report also notes that several of the tested red yeast rice products contained citrinin, a potential kidney toxin produced by the yeast. I think this is an important point. Even if all red yeast rice products still contained lovastatin, they would be less desirable than statin drugs, in my opinion, because of the poorer control over their manufacturing.
I contend that statins are one of the top ten discoveries of modern medical science. Not only do they decrease LDLs and inflammation, but they also stabilize atherosclerotic plaques and actually decrease their size. If anybody isn’t familiar with statins, re-read that sentence. They fight cardiovascular disease on so many levels.
Any CAM practitioner who recommends against statins is directly contributing to the death of their patients. Honestly, I don’t see how people like Joe Mercola can maintain their medical license in spite of recommendations that are diametrically opposed to the current standard of care. Jann, do you know? Is it because he isn’t directly treating patients?
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In other news, in our area there is a chiropractor who has gone off the deep end. He started trying to treat autism with hyperbaric ROOM AIR (not just oxygen!) He started appearing on local TV as a “chiropractic neurologist,” and claims to treat diabetes, Hashimoto’s, etc. He may have had a slap on the wrist by the chiropractic board. Then, strangely, he started rapping (yes, you read that correctly) about chiropractic, and apparently he performs chiropractic raps at chiropractor conventions. In other words, he’s conventional chiropractic scum.
To illustrate the issue with “shruggies” and CAM…
during my family practice rotation we had our weekly meeting with the head of the rotation and were discussing cholesteral therapies. The question of RYR was raised and the quick consensus around the room was “RYR is a CAM that works well. I don’t know much about it and would be a bit skeptical of recommending it to a patient, but if they are using it then I don’t see any reason to advise them against it.”
I commented that the MOA was that the yeast actually produced lovastatin and that it was entirely akin to taking a highly adulterated form of Lipitor with unknown amounts of both intended and unintended active ingredients and would thus recommend patients not take it (same as for any other herbal supplement).
I was roundly met with amazement at how I know “so many different things” and everyone now suddenly felt like they were better equipped to manage a patient with RYR and advise them appropriately – including counseling them to stop or switch to a regulated pharmaceutical.
The point being that even our attendings are poorly informed as to exactly what is up with all this stuff, and the default is to be a shruggie about it. Once I educated them on exactly what is going on with RYR that changed palpably.
Funny, Some people (including myself) think twice before buying poorly regulated imported toys or pet food, but some of those same folks think nothing of consuming poorly regulated imported or domestic supplements or giving them to their child (or pets).
Probably because we haven’t had any major news worthy supplement manufacturing errors as has happened with pet foods and toys.
I just wanted to mention how much I’ve enjoyed reading your articles lately, HH. Not only are they very readable/understandable to a non-science person such as myself, but they well organized, concise, entertaining and….well catchy.
Very nice hook – “Only it doesn’t anymore.”
NCCAM has a fact sheet on red yeast rice on their Web site. They just published it a month ago. http://nccam.nih.gov/health/redyeastrice
Here is a [free] article with a few key findings from the Consumer Lab tests:
http://www.medpagetoday.com/Cardiology/Dyslipidemia/22973
It looks like the statin levels per pill range from the low range of prescription levels down to almost nothing. And on top of that, some had a possibly-toxic substance (but they don’t say how close it is to being harmful).
I just saw a new(er?) episode of Dr. Oz today and he had Dr. Weil on there talking about his better health stuff and his anti-cancer super meal (because you want the super version and not the regular one I guess). And Dr. Oz mentioned RYR but I assume is unaware of the fact that all RYR in the US should not have the lovastatin therefore is useless.
As a side note about the anti-cancer meal I thought it would be some vague an obscure foods it make it seem plausible. But to my suprise it wasn’t, all it was is really a standard red pasta sauce with capers in it. Cut tomato, olive oil, black olives, garlic, basil, tuna, and capers. So why do we have cancer? That is pretty standard food we all eat regularly (except capers and olives for me). So sad that people will believe without question that the meal will have anti-cancer properties. Oh and it’s not just one it’s all cancer, because you know… all cancer is totally the same.
Red Yeast Rice (Hong Qu Mi in Chinese Pinyin) isn’t in most Chinese Herbal Materia Medica texts. It was mainly used a s a food coloring agent, though had a small reputation as helping with digestion (a handfull of rice itself is sometimes added to bitter or harsh decoctions to act as a buffer). I carried it in my Chinese herbal pharmacy for years. My goal was to carry every legally available TCM herb and make them accessible to “responsible adults” without making drug claims for them. I sold it by the pound, about $10/lb, and only sold about 10 lbs/year; I discontinued it about a year ago. The Chinese herb importer I got it from no longer stocks it as well.
The TCM industry reported that they couldn’t import and market an extract standardized for lovastatin, just the whole herb. I still get a little torqued when I see Red Yeast Rice extract capsules on the shelf at Safeway, etc. There’s very little logic, level playing field, or consistent law enforcement in CAM.
I prefer to buy bulk Chinese herbs from a top supplier who carefully heat-dries them and uses and air-tight double-bag system with nitrogen injected between the two bags. This takes care of the live insect problem, something I encountered in virtually every TCM herb pharmacy I interned in. I bought the Red Yeast Rice from a secondary supplier in a ‘normal’ cheap plastic bag (sometimes these have intentional holes in them to release moisture or allow fumigation). Live moths developed from tiny larvae in the bag. Of course, having a Chinese moth infestation in my pharmacy is unacceptable (the smaller, hard bugs that can bore through plastic and hard roots are another story). Out went the Red Yeast Rice (sealed in thicker bags, then frozen for a few days first). New stock was immediately rebagged and frozen. The customers were advised to not eat it raw, but to boil it first. I found no credible information about dosage. These factors don’t combine into a good sales pitch, thus it’s discontinuation.
My libertarian-leaning attitude of “provide legal access for responsble adults who know what they are looking for” continues to be challenged by reality. For example, the rarely used Magnetite (Ci Shi) in a TCM pharmacy had a sales spike when a product called Magneurol was heavily promoted as an ESP pill. I didn’t mind reducing the sales of Magneurol, but grew concerned about iron toxicity and the deluded delusions of my customers…
@Jimmylegs
Well, I eat the capers and the olives as well, and I don’t have cancer yet–so there, it must be true! You, of course, are doomed.
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Co-incidentally, I have talked with three people while on my road trip who have been told by an MD to either lower their cholesterol through (gasp!) DIET, or to start a statin drug. All three have refused to consider “taking a pill”, yet have little intent of doing much about their diets. Two mentioned that they would look for something “alternative” and one mentioned red yeast rice. I will send her this post–and thanks because I didn’t know the history of this product and had a vague idea that it was one of those that, at least sort of, worked. Rather amusingly, I have been calling this stuff red rice yeast–I though it was made from “red” rice I guess. 0_0
@ mousethatroared:
“Probably because we haven’t had any major news worthy supplement manufacturing errors as has happened with pet foods and toys.”
That’s because NOBODY HAS REALLY BEEN WATCHING the supplement manufacturing industry for far too long!
“Each individual constituent has been shown to control existing normal cholesterol levels”
What does this mean? They gave the pills to people with normal cholesterol levels and afterward they still had normal cholesterol levels? Yikes!
@BKsea:
It’s fine when drugs are used to maintain normal levels, but I would like to see the research the company did to come to this conclusion. What were their diets during the trial? Was there a follow up after the trial? How long was the trial? Size?
I assume you are saying they used an drug on normal people and they stayed in normal levels, meaning it did not work. Please let me know if I read that wrong cause it seems a little vague to me.
A lot of questions and I’m afraid there are very few answers, if any. I doubt any research by Pharmanex (Nu Skin) even exist seeing that it is more or less a multi-level marketing company (read: pyramid scheme) so that is a red flag in my opinion.
@SkepticalHealth
So why aren’t statins available OTC?
Yes, there are rare but potentially very serious side effects. Isn’t that why god made IFUs (package inserts)?
There are very good reasons for some drugs to be available only by prescription; antibiotics leap to mind. But many others could and should be available OTC – as they are in a variety of foreign countries.
How many hours of scarce and expensive physician time was spent asking Ms. Jones about her heartburn while proton pump inhibitors (prilosec et al) were prescription drugs? Now they’re readily available in every drug store and supermarket.
There have been proposals to make statins an OTC drug. The FDA ruled against it. This editorial in NEJM explains why: http://www.nejm.org/doi/full/10.1056/NEJMp058025
Basically, statins treat a condition that patients can’t self-diagnose; patients have no way of self-monitoring response, and they might be getting inadequate treatment or ignoring other risk factors for CVD; they can’t self-diagnose adverse effects like liver disease; and the prescription statins recommend monitoring liver function tests at regular intervals; and the drugs have not been proven safe for special populations like pregnant women (and they might be taken by women not yet aware they were pregnant).
@Dr. Hall
With all due respect, suggestions of hypercholestorlemia are easy enough for a person of reasonable intelligence to spot. I am not suggesting though that people should self diagnose – though I would argue that is their right if they choose to be stupid. I am suggesting that once diagnosis is confirmed, the dosage titrated and side effects ruled out, that patients not troop back to their physician every 6 months to get a new prescription.
I was prescribed a statin in the past (on the grounds that normal cholesterol is good but low cholesterol is better) and the biannual kabuki was a 10 minute visit that consisted of ‘hi howya doing, what’s your daughter up to?, been dove hunting yet this season?’ and out the door with a new scrip; a pleasant exchange but a waste of valuable resources on both sides of the equation.
“and the drugs have not been proven safe for special populations like pregnant women (and they might be taken by women not yet aware they were pregnant).” And seeing one’s physician every 6 months for a scrip renewal impacts this exactly how?
@windriven,
“Suggestions of hypercholesterolemia are easy enough for a person of reasonable intelligence to spot.”
Really? What do you mean by that? Most people who have elevated cholesterol levels aren’t usually aware of it until a blood test is done. And a titrated dose may not remain titrated, and side effects can’t be “ruled out.” Some of them can develop even after long usage. The fact that you apparently didn’t appreciate that underscores the value of consulting a doctor.
Now you are moving the goalposts. First you suggested statins should be available OTC and now you’re saying refills should not require a visit to a doctor, which is an entirely different matter. By the way, in my experience doctors usually write prescriptions for a year’s refills, not just 6 months.
There is value to a doctor’s appointment that may not be readily apparent to a patient: the entire risk status can be re-evaluated, other factors can be addressed that may have impact on the need for statins or the dosage, the doctor can ask about symptoms that the patient might not have connected to the drug, liver function can be monitored, and the doctor may have new information that might affect dosage, target numbers, or special populations. Just one example: one specific statin was recently found to interact with a certain BP med, and doctors were switching their patients to a different statin. Admittedly, pregnancy could be covered by a package insert warning, but new concerns can’t be foreseen.
The UK has an intermediate solution: a behind-the-counter option where a prescription is not required but a consultation with a pharmacist is.
FDA policies are certainly open to question; but as they currently stand, statins don’t meet the criteria they are using for designating a drug OTC. They have good reasons, but reasonable people may have other reasons to disagree with their decision.
@windriven:
Ahhh hypercholesterolemia is not easy to spot as it is asymptomatic, so we require blood tests to diagnose it. Also if you are arguing the point that easy to spot/diagnose conditions should not require prescriptions or renewals of, is a horrible position. What about hypothyroidism, after it’s diagnosed should the patient never require blood work or a new dosage ever again? What about depression, should they never be reevaluated to increase, lower, or even stop taking their drug (or switch due to ineffectiveness/side effects)?
The answers to all, including hypercholesterolemia, is no (kind of a double negative here): patients need to be reevaluated for their conditions. I understand if you may think this is stretching it but how do you justify that disease vs others in terms of “one and done?”
Also your biannual visits may be like that, but others may have more intense evaluations with their doctor drilling them with questions to be thorough.
“What do you mean by that? Most people who have elevated cholesterol levels aren’t usually aware of it until a blood test is done. ”
Screening tests are available everywhere from shopping malls to drug stores. Anyone with modest interest in their health has the opportunity to screen for cholesterol, high blood pressure, receive influenza vaccines, etc.
“What do you mean by that? Most people who have elevated cholesterol levels aren’t usually aware of it until a blood test is done. ”
And this was exactly my point: using valuable physician time for routine prescription review is unconscionable in a nation that spends nearly twice that spent per capita by other industrial nations with, at least by gross measures, nothing to show for it. No moving of goal posts involved.
@windriven,
“Anyone with modest interest in their health has the opportunity to screen for cholesterol’
Yes, consumers can have their cholesterol tested, but it’s not a simple matter of “Chol high = take statin.” Consumers don’t have the knowledge and judgment to determine what their level means in the context of all the other cardiovascular risk factors and whether statins are truly indicated, and if so, which ones and what the dosage should be. I gave the example of one statin that interacted with a BP med; I doubt that any consumer is aware of that and would know to switch statins when starting the BP med.
“No moving of goal posts involved.”
Yes there was. Your original goalpost was that statins should be OTC, then you moved the goalpost to not requiring a physician visit for refills when a patient is established on a medication.
“using valuable physician time for routine prescription review”
I would argue that that is one of the most essential roles of a physician in this era of polypharmacy: routinely checking which prescription and non-prescription meds a patient is taking and reviewing the need for each, possible interactions, etc. Your objection to unnecessary appointments could be answered by providing more liberal refills over a longer time period whenever that is safe and reasonable.
Part of the reason it is challenging to get certain supplement products off of the market is because companies have to ‘prove’ it was their product specifically that caused adverse effects. Companies can always claim that their product was not taken as directed…or blame other items being consumed for adverse effects. How long did it take to get Ephedra banned in the US, even after many serious health and death reports? It is just frustrating that people will gobble up these type of supplements…while eating their Big Mac…and wonder why they can’t afford to ‘eat healthy’ and other effective treatments?
This would never happen to a drug, because the drugs have to be shown to be safe prior to public use. The side effects would have been found out right away!
windriven “And this was exactly my point: using valuable physician time for routine prescription review is unconscionable in a nation that spends nearly twice that spent per capita by other industrial nations with, at least by gross measures, nothing to show for it. No moving of goal posts involved.”
A routine prescription review is a 15 minute appointment, maybe with a blood test that would have to be done regardless. How do you know you aren’t being penny wise and pound foolish? What are the potential costs and amount of time spent in the doctors office or ER from missed side effects, inappropriate drug combinations or missed signs of progressing disease?
Maybe I missed something, are statins OTC in other countries that have more efficient health care than the U.S.? What is your evidence that OTC statins would, overall, reduce the cost of healthcare?
@Dr. Hall
“Your original goalpost was that statins should be OTC”
No, I asked SkepticalHealth whom I presume to be an MD why statins aren’t OTC. I noted that there were a number of formerly prescription drugs that are now OTC and wondered if statins would fit this profile. I can purchase statins OTC in Mexico and in China. I don’t know about Europe beyond your note that they can be purchased in the UK with a pharmacist’s blessing.
@mouse
“A routine prescription review is a 15 minute appointment”
Perhaps for the physician but not for the patient. Why not have that routine prescription review handled by a PA or skilled nurse practitioner? Why not have annual renewals (apologies to Dr. Hall but in the real world physicians don’t write 1 year prescriptions and if they did I again have to wonder what the magic of a year is, why not 2 or 5 or forever? If we’re going to have a protocol shouldn’t there be a solid rationale on which to base it?).
@windriven,
“No, I asked SkepticalHealth whom I presume to be an MD why statins aren’t OTC”
Yes, you originally phrased it as a question, but I can only assume that you asked it because you thought it would be a good idea, and you followed it with the assertion that apart from antibiotics, “many other”prescription drugs should be available OTC.
I would be concerned about quality control for OTC statins obtained from Mexico or China.
Incidentally, narcotics used to be available OTC. Today, most people think restrictions are a good idea.
“in the real world physicians don’t write 1 year prescriptions”
Nonsense! I live in the real world and both my husband and I routinely get prescriptions refillable for 1 year, including my statin prescription.
As you point out, a 1-year period is arbitrary. There are no studies showing the optimal time for refills, and in the absence of evidence, a year is a convenient guess. It would be very costly to study that question for each of the many prescription drugs or even for the most commonly used ones, and there are other needs calling for our research dollars.
@ Dr. Hall
“Nonsense! I live in the real world and both my husband and I routinely get prescriptions refillable for 1 year”
Dr. Hall, you are a physician and your husband is the husband of a physician (and perhaps a physician himself). While not a physician, I work in the medical industry and through contacts and friendships have a relationship with my primary care physician that allows many things to be handled with an e-mail or a phone call. But that is not the experience of many people. Many people have to book appointments weeks in advance, sit in waiting rooms long after their appointment time has come and gone, and never get year long prescriptions. Many people don’t have the luxury of shopping primary care physicians to find one that adheres to scientific values and isn’t a douche, a quack, or a serial malpracticer (or?). In point of fact while I can generally get a prescription with a phone call, I’ve never had a 12 month prescription for anything.
“but I can only assume that you asked it because you thought it would be a good idea”
I asked it because I thought it might be a good idea. I’m still not convinced that it isn’t – at least within the scope of something like the UK model of OTC w/ a pharmacist consult. But I’m more interested in the larger issue of intelligently allocating scarce medical resources to achieve the greatest good for the most people (and hopefully at a cost more in line with other industrialized nations) than I am in the vagaries of statin prescriptions. Statin prescription practices need to be critically examined just like other allocations.
“There are no studies showing the optimal time for refills, and in the absence of evidence, a year is a convenient guess.”
You say 12 months, another physician says three. Where does clinical judgment stop and whim begin? Isn’t it just as reasonable to have a frank discussion with the patient about potential side effects and their warning signs and send them on their way to purchase statins OTC with the take-home that any signs of muscle weakness etc. necessitate an immediate call to the physician’s office?
hmmm, I’m a regular nobody patient and all of my chronic condition prescriptions are for a year. For the albuterol and Flonase, I’ve gotten extensions past a year with a call to the office script refill line. The synthroid, they get testy if I don’t come in for a TSH test after a year.
i don’t take (need) statins, though, so I can’t say there.
I’d also note that doctor’s ask every visit if you need any prescription refills. So, if one is at the doctor for a cough, sore foot, etc, one can ask for neededrefills then.
Windriven “Perhaps for the physician but not for the patient. Why not have that routine prescription review handled by a PA or skilled nurse practitioner? Why not have annual renewals (apologies to Dr. Hall but in the real world physicians don’t write 1 year prescriptions and if they did I again have to wonder what the magic of a year is, why not 2 or 5 or forever? If we’re going to have a protocol shouldn’t there be a solid rationale on which to base it?).”
I don’t understand your point. Of course a 15 minute appointment takes more time for the patient, but your argument was scare doctor resources, not patient convenience. Nurse Practitioners do presently write and refill prescriptions, what has that have to do with making statins (or similar medications) OTC.
With the coming patient satisfaction requirements as quality indicators, maybe a 1 year prescription for Vicodin will become common? Getting back to statins. The requirement for routine LFT monitoring has been dropped. So, I don’t have a problem prescribing statins for a year, as long as the patient’s LDL is at goal. http://www.fda.gov/Drugs/DrugSafety/ucm293101.htm
@windriven,
“Isn’t it just as reasonable to have a frank discussion with the patient about potential side effects and their warning signs and send them on their way to purchase statins OTC with the take-home that any signs of muscle weakness etc. necessitate an immediate call to the physician’s office?”
No. I have tried to explain why that would not be in the patient’s best interests. Apparently you don’t know enough about the complexities to understand what I meant. I agree with the FDA that making statins available OTC is not a good idea.
I strongly encourage the use of PAs and nurse clinicians and I am in complete agreement with you about the need to better allocate scarce resources. But I don’t think increasing the availability of drugs OTC is the answer.
If you think I get better treatment and longer refills because I am a physician, you are wrong. I get my medical care through the military system and they are regimented to treat everyone the same. Half the time they don’t even know I’m a doctor. The nurse calls my name as “Mrs. Hall” and they usually assume I’m a dependent wife. I have had to wait for appointments and have sat in the military pharmacy awaiting my turn for as long as 5 hours. I don’t get to choose a physician but am assigned one arbitrarily. I’m being followed in the cardiology clinic, but have never seen a cardiologist: my appointments there have been with PAs and nurse practitioners. I have never had any special treatment because of my rank or my profession, except once when they offered me the chief of anesthesiology instead of the nurse anesthetist; I chose the nurse.
weing “With the coming patient satisfaction requirements as quality indicators, maybe a 1 year prescription for Vicodin will become common?”
(rant)
Hah! Because there are not healthier ways to improve patient satisfaction? From a patient here’s a few tips.
-Don’t hire concentration camp guards to answer your phones and make appointments. (Or give THEM the 1 year prescription for Vicodin)
-Don’t have the person who leaves snippy notes in the break room saying “We’re not your mother, etc” write the letter that goes out to all new patients.
- If you give a patient a health history form that takes an hour to fill out, find some way to show that you actually looked at it.
- If you have a phone system that requires patients to leave a message for test result, refills or to talk to a nurse, makes sure those messages are answered in the time the message states…24 hours usually means 1 day, not 1 week.
- If your patient is making an effort to be reasonable and polite refrain from rolling your eyes, acting put out, snippy or grumpy. Also refrain from complaining about your staff or the patient’s other doctor(s) to the patient.
- Get a computer system where you can share records with other doctors in the area so your patients don’t have to spend an hour on the phone and another two hours running around town signing forms and collecting films and lab results.
- keep your computer testing equipment working…or at least advise staff to struggle with software/hardware problems outside the patient’s sight.
- Try not to talk to fast.
- Try not to interrupt more than necessary (yeah, I’ve worked with clients, I understand, sometimes it’s necessary)
If you are already doing ALL those things, I’m guessing you’d be ahead of the game in “customer” satisfaction surveys. You’d certainly be doing better than the doctor’s offices I’ve been to lately.
Of course, the endless supply of Vicodin is probably an easier route to customer satisfaction.
(end rant)
@mousethatroared
Excellent rant!
@Harriet Hall
Have statins been universally endorsed for primary prevention of coronary heart disease? I thought that this was still controversial.
@agitato,
“Have statins been universally endorsed for primary prevention of coronary heart disease?”
No. There is evidence that they reduce cardiovascular events and all-cause mortality, but the studies have shortcomings and it is still controversial. See this 2012 Cochrane review:
http://summaries.cochrane.org/CD004816/statins-for-the-primary-prevention-of-cardiovascular-disease
Current practice is to use statins selectively for primary prevention in patients who appear to be at high risk when all their risk factors are considered as a whole.
@mouse,
“- If you give a patient a health history form that takes an hour to fill out, find some way to show that you actually looked at it.”
That made me laugh. It is one of my pet peeves. Especially when the questionnaire repeats the same question on the front and back of the same sheet. Even when the doctor acknowledges part of the questionnaire (“I see you’ve had a hysterectomy.”) he fails to comment on other items that could be important or even red flags.
FTFY.
“I have tried to explain why that would not be in the patient’s best interests.”
Yes, well, 3 months, 12 months, sounds more to me like “because I said so” than an explanation. I’ll spend some time on Pubmed this weekend. Of course I’m probably not smart enough to understand those big words.
@windriven,
“Yes, well, 3 months, 12 months, sounds more to me like “because I said so” than an explanation.”
The time period is arbitrary and based on professional judgment (informed opinion). I tried to explain why followup at some interval is in the patient’s best interests and OTC availability is not, and I said we have no data to support any specific interval.
@ Dr. Hall
“I said we have no data to support any specific interval.”
Which brings me back to one of my interests and the primary reason that I follow SBM: allocation of medical resources in a way that delivers the biggest bang for the most people at a given expenditure of funds. Prophylaxis, diagnosis and treatment based on solid science seems to me an important component, arguably the most important component for approaching that goal.
When quacks tout reiki or spinal manipulation or tweedling needles it is absolutely appropriate to ask for proof. When a physician advocates a course of treatment it is also appropriate to ask for proof. Sometimes there isn’t any; apparently that is the case for frequency of patient follow up on a statin regimen. But invocation of clinical judgment doesn’t settle the matter. Clinical judgment is acceptable absent better information – but then the consumer has to evaluate how much faith to place in that clinical judgment – and the consumer rarely has the information to make a truly informed decision.* **
Medical wisdom changes. Some physicians spend a lot of time and effort keeping up with their field, others not so much. Internists and family practitioners have a particularly difficult task because they have to be up to date on an incredibly broad range of subjects. Clinical judgment and experience are fine attributes, especially in the realm of diagnosis. But they don’t hold a candle to solid scientific evidence when it comes to treatment.
I don’t know what the rate of rhabdomyolysis or liver damage are with statins. I especially don’t know the odds of either developing after long term use of statins. If I have an opportunity this weekend I’ll try to find out.
In the event, whether or not statins should or shouldn’t become available OTC isn’t the point. The evaluation of the expenditure of resources versus the good achieved is the point. This very blog has discussed routine mammographies and PSAs in the context of exactly that: how much do we spend to, say, find one cancer? With statin follow-ups how many physician visits per patient per decade yield the best balance between dollars spent and outcomes achieved? If medical care was free or unlimited dollars were available for medical care, or there were in infinite number of physician visits available, none of this would matter. Unfortunately it does matter.
*One can easily speculate that this is the door through which some people pass on their way to sCAM
** Even educated, thoughtful, interested consumers are faced with daunting costs in time and money to gather information on which to base judgments. Many journal articles – even those that issue from tax dollar funded research – are behind paywalls. $30 isn’t much if one can find a silver bullet by the abstract but when it takes 8 or 10 it can run into more than Starbuck’s money.
@windriven,
“it is also appropriate to ask for proof…With statin follow-ups how many physician visits per patient per decade yield the best balance between dollars spent and outcomes achieved?”
I agree with you. I would love to know that sort of thing, and it’s good to ask those questions and it’s important to do everything possible to increase efficiency and reduce costs of medical care. Meanwhile, we don’t have answers and we still have to write something in that space for the number of refills on the prescription pad. Clinicians are doing the only thing they can do in the absence of science-based guidelines.
One caveat: if we had a study showing that the best outcomes were in patients given 2 years’ statin refills, it wouldn’t automatically apply to everyone. The subjects in the study would have been selected to rule out confounders and wouldn’t be representative of the patient walking into our office who has 3 other chronic diseases and is on 8 prescription drugs. There might still be reasons for seeing individual patients more often. For instance we might have reason to suspect that an individual was at high risk for liver disease or was on other medications that might affect liver function and we might want to check his liver function tests at more frequent intervals. Medicine is complex, not a black and white cookbook. More studies would reduce guessing but wouldn’t eliminate it.
So with this discussion of follow up intervals what is actually being argued here? Is it that it should be shorter? Or that we need to find the best interval with research, which I don’t have the slightest clue as how one would figure that out.
For the time being it what we have doesn’t seem bad.
@windriven:
You seem to be focusing on the concept that the only reason for the return to care after 6 or 12 months would be the statin refill script. Perhaps in your case it is. And as you said, there are some crappy docs out there. If the only thing is the statin script, then yeah you’re right. Pretty pointless. However, it is valuable for a patient to follow up with his/her doc regularly. A year is the arbitrary time frame we have for that in general. If your doc won’t write a script for a year well… I dunno what to tell you. When I did family medicine we wrote for a year on meds we figured were good to do so. If a patient needed a script and nothing else, and the clinical judgement was that there was no other reason to see the patient… well, we filled it over the phone! Or even by email, actually. And if a patient came for some other reason outside the scheduled yearly return, we always asked if they needed a refill on anything.
So your singular experience with which you are trying to paint the whole of medicine an somehow claim that you have a special insight to is old hat. We know this, we do this already. It is how I am being trained. And besides, your initial post and the starting point of discussion was specifically making statins OTC and then generalized to making meds OTC as the solution to this perceived resource wasting problem. The better solution is exactly what I described above.
@Jimmylegs
“So with this discussion of follow up intervals what is actually being argued here?”
Speaking only for myself, it became an inquiry into the relationship between best practices and clinical judgment and how the result impacts costs and outcomes. But it started as a question about why one particular family of drugs isn’t available OTC.
There have been any number of drugs that began life as prescription drugs. H2 blockers and proton pumps and allergy medications leap to mind. Sometimes physicians argue as Dr. Hall did here that it is in the patients’ best interests to have drugs available by prescription necessitating physician follow up visits.
Here we drift into an area of relative benefit versus relative cost. There would be fewer traffic fatalities if speed limits were kept below 30 miles per hour, cars were built like battle tanks and only licensed chauffeurs could operate them. But the cost of transportation would be astronomical.
In America the cost of healthcare is astronomical measured against the cost of care in other industrialized nations. Worse, at least by gross numbers, we don’t have large incremental improvements in outcomes to show for the added expense.
Life is full of risks and with those risks come potential benefits and potential damages. When you take a statin you are hedging your risk of cardiovascular disease but incurring a risk of (rarely) devastating muscle or liver damage. Having a physician mediate reduces that risk but comes at a cost in both real terms and in terms of opportunity cost because health care is a finite resource. Where do you draw the line?
@windriven,
Let us know if you find any good studies of optimal patient follow-up. My own approach to refills and f/u varies with the patient. If the patient’s cholesterol is at goal on the current dosage, I don’t have a problem giving refills for a year, especially since quarterly LFT monitoring is no longer required. Again, this is only anecdotal, but I have found that some patients become lackadaisical about adhering to their diet and medication use when they are given refills for a year. It’s as if they feel that if I don’t care enough to monitor them, why should they?
@agitato – Thanks
HH – Somehow I thought that a doctor would never ignore another doctor’s health history form…
Scott – HeHe – if ignoring one form is good, ignoring two forms must be better.
@windriven:
Ok I think I understand what you are saying. For some drugs that are prescribed for 6-12 month supplies physicians based that on trends. As an anecdote my dad takes medicine for cholesterol and hypothyroidism. He goes in every 6 months or a year (I don’t know the exact times, but it’s not frequent) and when he gets his blood work done his medicine is based on the changes (if no change, it remains the same dosage).
Now the arguement (if I understand correctly) is why 6 months? Why 12 months? Why not just have it OTC? Well I cannot answer the intervals because 1) I’m not a doctor and 2) I don’t know the methods / reasons for any blood test / testing interval for drug renewal, but the OTC question seems to have been answered.
Statins are not OTC because they require more than personal judgement on what you need and when you need it. I think you would be hard pressed to find anyone in the world that can give a statin dosage for general populations assuming we have the same cholesterol levels, so we need that blood work at a minimum to get started. So ruling out “time wasted” at a doctor, then going to LabCorp or Quest to get work done will still be there.
So on the bases of requiring blood work to be done I doubt any statin (unless a new one comes out that is realitively safe and “one dosage fits all”) will be OTC ever.
I actually know a few cardiologists from back before I started med school who said something to the effect that “statins should be put in the water alongside fluoride” because of the amount of good it would to for the population and the risk profile.
I don’t know that I would go that far. The problem with making statins OTC is exactly what was said above – you have absolutely NO idea if you actually need it. I have a friend who is 4’8″ tall and weigh between 210-230 pounds. She eats poorly, as you may imagine, is in her mid 30′s and has better cholesterol than I do. I am in my late 20′s, 6′ tall, weigh around 185-190 pounds, and in my peak (which is when we both got our cholesterol panels done) I was cycling 3-400 miles per week, running 20-25 miles per week, surfing 3 times a week, and lifting weights 2-3 times per week (obviously, this was before med school started…).
Any person in their right mind would look at me and assume my cholesterol was fan-friggin-tastic. And look at her and assume it was faaar from so.
So the harms would not only come from people who need a statin and get side effects but from all those people who don’t need a statin and take one anyways (risk:benefit where benefit is extremely small) and from those who do need a statin but then don’t take it because they assume they don’t need it.
For the drugs mentioned above there are really obvious indicators when people should take them and the side effect profile is at least as good as a statin. Have an upset stomach? Frequent heartburn? Try a PPI or H2 blocker or Tums. Have runny, itchy eyes and sneeze a lot? Well an anti-histamine makes sense. Have muscle pain? An NSAID seems like a good choice.
The other aspect is that in each of these commonly OTC ailment/remedy combos the ailment is typically self-resolving and the treatment is typically not taken for years on end. Stomach ache doesn’t go away after a couple of days of OTC? Then follow up with the doc and figure it out. Sinus congestion terrible and won’t go away with a Claritin? F/U. Reflux so bad the PPI doesn’t touch it? Same thing… and of course, if the PPI does work then we would tell you to take it for years anyways.
Many drugs and supplement are OTC that many here have argued shouldn’t be, so using them as examples is not so valid. My own example of NSAIDs could reasonably argued as such. Especially aspirin and tylenol. But as we all know the NEJM showed us that regular vitamin takers had increased mortality and morbidity…. people who almost certainly had no need for the vitamins and of course what they were taking is probably much more innocuous than a statin.
“and of course, if the PPI does work then we would tell you to take it for years anyways.” I am not so quick to do that. I tell the patient to take it for 2 months and stop. If they have to resume it, I send them for an EGD first to rule out anything more serious. Then, I tell them to take it for years.
excellent point, weing. You are correct – sinister causes need to be ruled out as well. Further demonstrating that OTC is probably an over stocked section of the pharmacy
@nybgrus, I did not read in detail so forgive me if this is unnecessary. UpToDate has a great article on the long term effects of PPIs:
http://www.uptodate.com/contents/overview-and-comparison-of-the-proton-pump-inhibitors-for-the-treatment-of-acid-related-disorders?source=outline_link&view=text&anchor=H59974871#H59974871
(I hope that link works.)
(I mean, I didn’t read what you wrote in context about PPIs)
Thanks for the link. It wasn’t anything surprising to me, though it does seem that PPIs are reasonably safe. Of course nothing can be completely benign when taken for an extended period of time.
@Dr. Hall,
As a libertarian, I’d love to jump in on the OTC vs. prescription discussion, but I have what I think is a more important question regarding the accuracy of this article. I’m a fan of the SGU, JREF, Dr. Novella in general, and I obviously visit sciencebasedmedicine.org.
This article states “Only it doesn’t anymore.” That’s what concerns me.
So that we can have a science-based discussion about this, I’ll include references to my sources of information and will look to you to poke holes in them if you think it’s deserved.
Background:
I talked to a doctor about a few years ago that recommended red yeast rice because it contains lovastatin. Knowing that herbal medicine companies aren’t regulated like the pharma companies, I wanted to do some research for the very reasons you discuss in this article.
Research:
Like @Old-skeptic, I found that consumerlab.org did what they assert was an independent test on many different red yeast rice brands and found that some did consistently contain the amount of monocolin K (lovastatin) as claimed on the label. That report is at https://www.consumerlab.com/reviews/Red-Yeast-Rice-Supplements-Review/Red_Yeast_Rice but requires an annual subscription to their service. I found one of the higher rated products on Amazon.com and can identify it if you want me to. I’m not sure if you would view listing specific products as inappropriate for this website.
Likewise, there is an article reviewed by Dr. Agus MD; emeritus professor of U of Penn School of Medicine based on the consumerlab.org research. (See http://www.medpagetoday.com/Cardiology/Dyslipidemia/22973) I don’t know if Dr. Agus really vetted the consumerlab research or just jumped on the bandwagon—this is one of the reasons I’m looking to you, on behalf of sciencebasedmedicine, to weigh in on this.
Another highly rated (by consumers) red yeast rice brand on Amazon.com lists a certificate on the brand’s website issued by an independent lab (See http://www.aaclabs.com/about/professional) which “seems” legit to me.
So there are at least two brands, available in the U.S., which claim to have lovastatin as contents, and also claim to have proof of their claimed content (lovastatin) by independent labs.
Question:
At this point, I’m wondering if you would consider updating your article based on this new information. If you have contradictory evidence, I’d like to read it. I’m not interested in winning an argument, just getting to the truth.
I appreciate you taking time to lend your expertise to this website.
@swithin
Below is the relevant passage from the FDA website. http://www.fda.gov/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocuments/DietarySupplements/ucm257563.htm See what you can make out of it.
Can I manufacture and sell a dietary supplement containing a dietary ingredient that was marketed as a food or dietary supplement before it was approved as a drug, licensed as a biologic, or authorized for investigation under an IND?
Yes, in this situation the dietary ingredient may be used in dietary supplements. In considering whether a substance has been “marketed as a dietary supplement or as a food,” FDA looks for evidence of one of the following:
Evidence that the substance itself was sold or offered for sale in the U.S. as a dietary supplement, dietary ingredient for use in dietary supplements, or conventional food. For example, a catalog listing a product identified as a “Substance A supplement” would establish the marketing of Substance A as a dietary supplement. Similarly, business records documenting that a substance was offered for sale or sold as an ingredient for use in manufacturing a conventional food would establish the marketing of the substance as a food.
Evidence that the substance was a component of a food or dietary supplement that was sold or offered for sale in the U.S., and that a manufacturer or distributor of the food or dietary supplement marketed it for the content of the substance by, for example, making claims about the substance or otherwise highlighting its presence in the product.[17] For example, in Pharmanex v. Shalala, the firm marketed lovastatin, a component of its red yeast rice product Cholestin, by promoting the lovastatin content of Cholestin.[18] Merely showing that the substance was present in a food as a component would not be enough to show that the substance was “marketed,” however.
@swithin,
I said “Most of them got around the FDA restriction by eliminating the monacolin content and by careful labeling and advertising that does not claim to lower cholesterol.”
“Most” doesn’t mean “all.” If any currently available brand contains appreciable amounts of monacolin, much less therapeutic levels of lovastatin, it’s illegal, and it’s only a matter of time until the FDA acts against it.
@weing
“Let us know if you find any good studies of optimal patient follow-up”
I’m sure you know but it bears repeating for other readers who may be new to SBM: I am not a physician. That said, there is an awful lot of material out there on statins but little that I could find that gives follow up recommendations that are both evidence based and specific. The best I found is:
“Final Conclusions and Recommendations of the National Lipid Association Statin Safety Assessment Task Force” published in the American Journal of Cardiology.
Unfortunately NLA appears to get a lot of its funding from major pharmaceutical companies so there may be good reason for some caution.
Conclusions and Recommendations discussed four adverse effects: changes in liver function, muscle disorders, renal disorders and neurological disorders. In discussions of all of these adverse effects clinicians are directed to be vigilant for symptoms (and these are enumerated) and to instruct their patients of symptoms that may warn of adverse effects. Careful evaluation is recommended prior to beginning treatment, for 12 weeks after beginning treatment and after dosage changes. And of course patients with other morbidities and those taking multiple drugs require more careful monitoring. But “routine monitoring of liver function tests is not supported by the available evidence.” Discussions of the other adverse effects similarly do not find available evidence supporting routine labs.
Still, as Conclusions and Recommendations notes, prudent physicians will follow FDA approved prescribing guidelines including periodic follow ups. But, at least from the evidence discussed in this paper and absent significant comorbidities, this has more to do with bureaucratic head-bobbing than quality patient care.
As to my question to SkepticalHealth about OTC statins, after a few hours of intense reading I still don’t have a strong sense of whether they should or shouldn’t be. The incidence of serious adverse effects is verrrry low but when they occur they can be horrific. These serious adverse effects generally occur where there are other serious comorbidities rather than in otherwise healthy adults – and those with serious comorbidities should be seeing a physician regularly anyway.
There are a finite number of primary care physician-hours available in any given year. How do we as a society best spend those hours to achieve the biggest bang for the most people? What can we do to leverage those hours; what force multipliers can we use? Where can we eliminate tasks that waste those available hours on non-productive activities?
@windriven,
It is a rare patient that is just on a statin. Most of them have various comorbidities. I have struggled with the question of optimum follow-up intervals ever since my residency in the early 80s. What I did is adopt what my preceptors did and what my fellow physicians did. That’s how a standard of care is determined anyway. Should something go wrong, I am not an outlier that can be blamed for not following up appropriately. Some of the intervals are based on science but all are based on what the doctors in my community are doing.
@weing
“It is a rare patient that is just on a statin.”
I wonder if this is as true in the general population as it is in your practice? I have quite a number of friends who are on statins on the grounds that low cholesterol is good and lower cholesterol is better. My own former internist had me on Lipitor for several years on the same theory (180 total ~5:1 w/o statins). I took myself off after a while – I don’t like taking drugs without a compelling reason – and my current internist sees no reason for me to resume. But frankly many of my physician friends (mostly anesthesiologists) also subscribe to the prophylactic statin notion regardless of baseline cholesterol.
@windriven:
You are misinterpreting the intention and purpose of the statin in such cases. There is pretty decent evidence and plenty of plausibility that the curve for morbidity/mortality vs cholesterol not only has an inverse correlation but also does not plateau.
Meaning that the lower your cholesterol is the better, without some magic number below which there is zero additional benefit.
By that basis alone some actually argue that statins are always a good risk:benefit.
I am with the middle ground here that any single risk factor is probably enough to be reasonably certain to tip the balance.
So being a white male over 40 is a risk factor. Diabetes, family history of CAD or MI under age 50, known CAD or athersclerosis, chronic poorly controlled hypertension, and a few others are risk factors. So pretty much at least half the population at some point meets criteria.
But that doesn’t mean it shouldn’t be monitored and managed (and titrated to proper dose). Hence, I still think OTC is a stretch… but not that much of a stretch. I could see a good epidemiological study at least potentially demonstrate that the overall risk with very large numbers of uptake was worth the net benefit to society. That would be a tough study to do (to put it mildly) but theoretically possible.
@nybgrus
“You are misinterpreting the intention and purpose of the statin in such cases.”
?
No, I don’t think I am misinterpreting it at all. But having no risk factors for CVD (other than my age), no family history of CVD and with statins not having been in widespread use long enough to establish their absolute safety when used daily for, say, 50 years I just don’t see the point. As I mentioned, my former internist in New Orleans was a true believer. My current internist in Portland is … not.
“Meaning that the lower your cholesterol is the better, without some magic number below which there is zero additional benefit. ”
Perhaps. Perhaps not. I don’t know that the effects of medically induced long term hypocholesterolemia have been carefully studied.
In any event, you and I agree that OTC statins is a moot point. If I had to choose today I would probably argue against. But I would also argue that otherwise healthy patients on statins should be followed after the first year or so – if at all – by a PA or RPh* or skilled nurse practitioner.
I have two reasons for my general philosophical opposition to having physicians personally involved in every detail of care. First, physician time is a limited and extremely valuable resource. I would like to see that resource exploited in the most efficient possible way so as to do the greatest good for the greatest number of people. Second, because physicians as wet-nurses distance people from their responsibility for their own health. It isn’t good for consumers and it isn’t good for physicians (think of how many pointless antibiotic scrips have been written in the past 20 years by physicians because their patients expected/demanded it).
* It seems to me that ‘lick, stick, count and pour’ is a gross under-utilization of pharmacists.
@windriven,
” I don’t know that the effects of medically induced long term hypocholesterolemia have been carefully studied.”
There are studies of people with PCSK9 loss of function mutations that have extremely low levels of cholesterol that do not show any adverse effects of extremely low levels of cholesterol except that they don’t get atherosclerosis. So, this question is pretty much settled, the lower the better. There are risks to the use of statins as well as benefits. If your Framingham risk is low to begin with, lowering your risk further may not outweigh the risks of the various adverse effects of statins, not even considering the cost of the meds.
I can’t say I know enough – i.e. have sat down and really crunched the numbers if they are even available – as to which way to cut such a thin edge. You do have a risk factor – your age. Is that alone enough to tip the risk/benefit analysis? Maybe, maybe not. If your cholesterol is higher than 170 total, then I would say that is very likely good enough reason.
And statins have been around – lovastatin specifically – for a long time. Marketed since 1987. And studied very, very heavily.
And as weing pointed out, there is indeed a fair bit of data to demonstrate that lower is actually better, regardless of how low you actually are. Obviously there are diminishing returns, but nonetheless the evidence is there.
As for making it a 1 year script, or one that is followed by mid level practitioners… you get no argument from me. And as I said – in my clinics this year we have prescribed for a year plenty of times. And back in my undergrad days I did some work in a heart failure clinic and it was the NP that took care of all that stuff.
As for your objection to having a physician involved in every bit of care… I also agree. However, the practicality of the situation is more complex than that. Mid level practitioners and a true team mentality for health care is a relatively novel concept and even more novel in implementation. Who is adequately trained and who you can trust is often a legitimate question. An NP who gets good at pattern recognition and succumbs to Dunning-Kruger is quite dangerous… and it is the physician’s license on the line. Not saying NPs are poorly trained – just pointed out that it is actually more complex than just saying “NPs should handle that.”
@weing and nybgrus
Sincere thanks to you both. I’ll do a bit more research, then discuss resuming statin therapy with my internist next visit.
@nybgrus
“it is the physician’s license on the line.”
This is more a legal / regulatory issue than a medical one. If we are to rebuild our health care system to offer quality care to all Americans at something closer to the cost of other industrialized nations we will need to address these issues. Tinkering with health insurance a la ACA is necessary but wildly insufficient.
@weing, you say that since mice that are genetically purposed to have lower cholesterol have no atherosclerosis, then it is given that higher cholesterol is a cause of atherosclerosis? I have paraphrased but this appears to be the gist of what you have said.
Isn’t cholesterol a risk factor? and is there any clear evidence that lowering a risk factor lowers the disease?
I remember about 5 yrs ago a statement issued by the AMA that they were naive in believing that cholesterol caused atherosclerosis since it was high is so many with atherosclerosis. This was in response to studies showing that statins did not actually lower atherosclerosis and in one case there was an actual slight increase when using one particular statin.
A phD friend of mine working at the UTHSC in Dallas said it was looking like the elevated cholesterol might be a response to something associated with atherosclerosis. He used an analogy I had read related to firemen and fires, that their concentration rises in areas of elevated occurrence of fire. Of course, using the same analogy, lowering the concentration of firemen would not decrease the occurrence of fires.
@nwtk2007,
“@weing, you say that since mice that are genetically purposed to have lower cholesterol have no atherosclerosis, then it is given that higher cholesterol is a cause of atherosclerosis? I have paraphrased but this appears to be the gist of what you have said.”
Huh? No. I was talking about PCSK9 loss of function mutations in humans not mice.
Oh der. My bad. Not sure where I got that? Any way then, same comment.
@nwtk2007,
I think your friend was talking about HDL cholesterol. That is a horse of a different color. The studies show that elevated HDL cholesterol is associated with decreased MIs. As far as I know, no studies have shown that raising the HDL cholesterol decreases the incidence of MIs. Only lowering the LDL has been shown to do that. The analogy of firetrucks is frequently used for it. If the firetrucks are just going around and not putting out the fires, or if they are themselves on fire, they don’t do much good.
I don’t think so really. I guess what I’m getting at is even though disruption of the function of the pcsk9 entity results in elevated receptors and thus a lowering of blood LDL-C, there is still the question of whether or not this lowered blood LDL-C results in decreased plaque formation or not. Its the same question; does lowering blood cholesterol decrease atherosclerosis of is the decreased atherosclerosis the result of some other thing, not specifically the lowering of cholesterol? Or the reverse, does the cause of atherosclerosis also cause elevated blood levels of LDL-C?
I genuinely don’t have the time to look it up and reference right now, but there are indeed studies of various populations with various levels of cholesterol that demonstrate decreased athersclerosis and cardiovascular risk. There was also at least one paper some years ago (which I read pre-publication) demonstrating evidence of actual reversal of atherogenic plaques once the TC drops below a certain value (I can’t remember exactly right now, but somewhere in the 70-80 range, so yes, quite low).
Furthermore there is bench science evidence to demonstrate how LDL gets trapped in the intima of vessels and the oxidization and inflammatory reaction that follows so there is indeed a priori plausibility that it is the increased LDL levels that lead to increased athersclerosis and not just some 3rd communally causal association (similar to how increased blood glucose leads to increased glycosylation – this is something that just happens all the time at a low basal rate so increasing the concentration of the reagents increases the rate).
The last bit would be a question as to the harm of extremely low levels of LDL or TC. And once again, as weing has pointed out there is evidence that there is very little harm though I will agree that is far from conclusive. However, it can very reasonably be argued that trading the potential harms of low TC for the definitive harms of CVS disease is a good bargain, since if the harms of low TC were even remotely as much as that of CVS disease we would have some evidence of their existence.
Lastly, I can toss in the evolutionary perspective as to why we would have a propensity for such a deleterious trait as cholesterol that kills us. First, our ancestors rarely had access to regular and significant amounts of food in order to generate a cholesterol level like what we see. But that is rather weak – the bigger part is that cholesterol is useful for a host of hormonal regulation (synthesis pathways) and the “high” levels wouldn’t kill us till LONG after we had procreated repeatedly so there is no particular selective pressure against the trait and at worst neutral selection for the hormone and lipid membrane synthesis aspect. In any event, this part is weak and I haven’t given it too much thought for this, but the point is that there is no evolutionarily compelling reason I can think of that would select against us having such a propensity.
Statins have an anti-inflammatory effect as well as lowering cholesterol. The bottom line is that treating patients with statins both lowers their LDL AND reduces their risk of heart attacks and death. We can go ahead and prescribe it without fully understanding exactly how it works.
^Not only that, but as part of their anti-inflammatory mechanism they stabilize and reduce the size of atherosclerotic plaques. They are, quite honestly, a wonder drug.
@nwtk2007, in case you aren’t following (I don’t mean that in a negative way), we know the following about statins: 1. they lower LDL cholesterol and have favorable effects upon other lipids, 2. they are fantastic anti-inflammatories, 3. they stabilize atherosclerotic plaques, and 4. they decrease the size of atherosclerotic plaques. We also know that decreasing the amount of LDLs leads to a direct decrease in cardiovascular mortality.
We know these things, and there is basically no debate or question to them. I hope everyone realizes how fantastic those few statements are. Those very same atherosclerotic plaques are the ones that either block arteries or embolize and block arteries further downstream. The fact that we have a medication (that is indeed mostly natural, isolated from fungus or something) that can not only stabilize these plaques, but actually shrink them, is absolutely fantastic. I sometimes think of statins as the second best class of drugs, behind antibiotics.
Around 20% of your LDLs ultimately (!) come from your diet (trans-fats, saturated fats), and 80% is made by your body. It’s interesting because you can improve your diet, and see a nice drop in your LDLs, but the fact is if you starve yourself of dietary fats your body will compensate by making more LDLs. Of course exercise, etc, can also help reduce LDL levels, but there is a finite limit to what you can achieve by hard work and diet. The other 80% of your LDLs are made by your body. This is where statins (HMG-CoA reductase inhibitors) work, that is, they decrease the LDLs made by your body. Statins are necessary because they can drastically reduce your LDLs, thereby decreasing your chance of dying from cardiovascular causes.
If anyone ever encourages a patient with hyperlipidemia to quit taking a statin (unless they are having horrible side effects) then they are directly contributing to that patient’s death.
Note: If you are interested in learning about these things, the first half dozen chapters or so of the book Harriet wrote about a while back, Heart 411, is a great starting point.
Other note: Any doctors out there, please counsel your nurses on calling patients with results from lipid panels. I’ve had a ridiculous number of extraordinarily healthy friends tell me that they got a call from their PCP’s nurses telling them they had high cholesterol, only to find out they have < 100 LDLs and fantastic HDLs (and of course good triglycerides.) Sigh!
Here’s a link to a “summary” of a book about cholesterol “myths”. Some of what you have said is consistent with it and some not. http://www.mnwelldir.org/docs/cardio/cardio8.htm
Nothing I wrote is a myth.
@nwtk2007,
So, some of it is correct and some of it is crap. You have the power and are armed with the knowledge to decide which is which.
http://www.sciencebasedmedicine.org/index.php/the-international-network-of-cholesterol-skeptics/
I did a quick skim. Almost stopped reading when I came across:
Yeah, CHF is not a big deal. Long term sequelae of “minor” heart attacks doesn’t matter. Its only people who die right then and there that count for anything.
And then I cam across this:
Which is doubly funny because at that particular site there was no reference, but in another there was. And the reference right below it was:
Quotation bias you say?
The whole abstract from which the Framingham quote was mined:
(Emphasis mine)
So lets see… under 50 we have a significant decrease in CVD mortality (and presumably morbidity) for decreases in cholesterol. Then, magically at 50 we better crank up the cholesterol in order to continue the protective effects? Even the authors realize this is a stupid assertion and thus we find there must be a confounder (or two) in play here.
That took me all of 15 minutes to skim and reference. But of course, I wouldn’t be reading such cheesy looking sites proclaiming wild things against the consensus, without references, and consider that a legitimate source of evidence. At least not without doing a little bit of legwork first. You need to up the caliber and quality of your reading material nwtk.
sorry, link to the other site didn’t work:
http://www.ravnskov.nu/weblit.htm#115
nygbrus, I’m really not trying to make a point. I wanted to see your take on it. But it would seem not to be a crystal clear issue.
@nwtk2007, come on man. At least try. Don’t link to a goofy article on a goofy website and then tell a bunch of people who are up to date with the latest science that what they are saying is myth.
Sigh.
I think nwtk2007 did a great job at exemplifying that chiropractors don’t have even the most basic understanding of the most basic things that are treated in general medicine. This is as basic as pointing to an airplane and identifying the wings. Its interesting that chiropractors spend all that time in school, consider themselves “doctors” (although no one else does), and yet don’t know squat about anything. What a tragic waste of time and money.
I sat here and wondered why all these CAM fraudsters purposefully obfuscate simple issues. It must be because they are all sidelined because their offerings are useless crap, so in order to sell their snake oil they have to lie about the issues, purposefully confuse people, and then lie directly to them.
@nwtk2007,
” it would seem not to be a crystal clear issue”
It is crystal clear to those who understand the science. The waters have been muddied and a manufactroversy created by those who oppose all drug treatments and by so-called cholesterol skeptics who have distorted a grain of truth into a whole edifice of misinterpretations and speculation. See http://www.sciencebasedmedicine.org/index.php/the-international-network-of-cholesterol-skeptics/
“But it would seem not to be a crystal clear issue.”
Try cleaning your glasses first.
you aren’t trying to make a point? Then why are you posting in the first place?
That sort of answer is a pretty stock and common one for various pseudoscience apologists (and poor debators in general) as a catch all of the “I’m just asking questions” defense. No matter how you slice it, it is a a sneaky way to slink off and still hold on to some part of one’s original assertion.
The issue is pretty crystal clear and the tack taken by you and the website you referenced is the same as that creationists and AGW deniers – find an inconsistency, minor hole, or small crappy paper that disagrees with the consensus and focus on that. It’s called a “manufactroversy” in that no reasonable and informed person would think there is a genuine controversy about the underlying principles and salient points.
Is absolutely everything, down to the tiniest detail, settled about this topic? Of course not. But the framework is pretty solid and well established. The whole of your argument is simply ill informed and at least nominally disingenuous. Not to sound too much like SkepticalHealth ;-p but that does make sense since you use the same tactics to try and defend chiropractic as a valid intervention for back pain.
I do think that this little exchange demonstrates that chiropractors, no matter how science based they claim to want to be, are truly anti-science and anti-medicine. Just another reason why no medical doctor should ever refer a patient and subject them to rank quackery.
“Oh, you don’t need your statin! LDLs don’t mean anything.”
… My wife has a friend who just got put on a new diet. It’s a 100% protein diet, consuming less than 500 calories per day. A chiropractor in Houston gave it to her. Wow. What a f-ing idiot.
Haha, I just Google-ed “nwtk2007″ and saw dozens of his posts across the internet over the last 4-5 years. Wow.
Some of those threads on chirotalk are absolutely hilarious. I do appreciate that a lot of them have realize that their profession is a complete joke and that they shouldn’t wield the title “doctor” and that they know essentially nothing. I just can’t believe how nwtk2007 knows basically nothing about one of the most fundamental aspects of cardiovascular disease. I mean completely clueless. It’s just embarrassing.
@nwtk2007, what exactly do they teach you in chiro school? I saw you’re 37, so it’s not like you passed through before any of this stuff was common knowledge. I just don’t see how you can be so completely devoid of basic knowledge.
Harriet:
“The waters have been muddied and a manufactroversy created by those who oppose all drug treatments and by so-called cholesterol skeptics who have distorted a grain of truth into a whole edifice of misinterpretations and speculation. ”
I love it.
Your responses are so revealing of your lack of objectivity, don’t you see? I truly just wanted your take on that website. It is obviously on the “crazy” side. Der. But since I am a chiro you just assume I’m trying to make a point? Get over your selves and you might make a difference; in somebody’s life I mean. You are mostly doctors, yes? Disappointed to be sure.
Actually I was hoping at least one of you might dicsuss the role of oxidized LDL in atherosclerosis. If I am not mistaken, there was a nobel prize given to a person who suggested that the initial event in plaque formation involved free radicals. I might be wrong about that.
@nwtk2007,
Oh. You was just joshin’. And I fell for it. Insert icon for: tail between my knees and cheeks flushed with shame. You wanted to discuss the role of oxidized LDL. From what you had posted, that would have been like discussing matrix algebra with someone who didn’t know addition and subtraction. Yes, it plays a role in atherosclerosis. I don’t know of any Nobel prizes for the role of oxidized LDL.
Here are some references regarding PCSK9 if you’re really interested:
http://www.hhmi.org/research/investigators/hobbs.html
http://www.nejm.org/doi/full/10.1056/NEJMoa054013
lol @nwtk2007. Troll harder!
Actually Weing, I believe it might have been Murad but his work was centered more on NO and local messengers so I might be wrong. It is interesting however, that is the initial event involves free radical promoted damage, as is also experienced with re-perfusion of ischemic tissues, then the role of cholesterol would have to be questioned. Just say’in.
Skeptical, whats a troll?
Those are really good articles weing. I saw those a few years back. Highly suggestive for sure, but I think the actual role of cholesterol/LDL’s is still misunderstood in that there might eventually be better treatments/preventions than heavy concentration on their reduction.
I also never found matrix algebra to be of that much use but many of my old prof’s used it in all their applications.
so because reperfusion injury is based on a burst of free radicals in tissues that are ischemic and thus unable to handle it, that calls into question cholesterol’s role in cardiovascular disease? Honestly I am at a loss. That is a complete non-sequiter.
and “highly suggestive” is basically what science does. It very highly suggests that time-space curvature is real, the relatavistic effects need to be taken into account, and that cholesterol is a significant (though not sole) risk factor for the development of cardiovascular disease. It is also “highly suggestive” that smoking leads to lung cancer. And most evidence demonstrates that the absolute risk increase is somewhere in the 1% range. Perhaps you would also suggest that we are concentrating on smoking cessation much too heavily? Or perhaps you just don’t understand the concept of the law of large numbers and targeting the easiest and safest risk factors first….
“Highly suggestive for sure, but I think the actual role of cholesterol/LDL’s is still misunderstood in that there might eventually be better treatments/preventions than heavy concentration on their reduction.”
Huh? Picture me scratching my not so luxurious mane. Let us know when we have them. So far this is the only thing that appears to work and that includes LDL-pheresis.
“I’m going to pretend to be interested in the nitty gritty details, but then deny the effectiveness of the whole thing anyway.”
nwtk2007, despite any claim of yours to be interested in “evidence”-based chiropractic or anything of the sort, the truth is, at your core, you are anti-science. I wonder if the same is true for all chiropractors. After all, does someone “learn” to be a quack, or are they “born” with the “ethical” part of their brain missing?
Discussing the depth of the evidence is not denying it. So defensive.
Skeptical, do you know just how much you sound like a white supremest, intolerant cult/church member?
Additionally, even if there is supreme evidence and understanding of cholesterol’s role in heart disease and heart attack, the use of statins for prevention as has been implied in this thread, would seem to be a very highly debated point in the medical arena. http://theunhivedmind.com/wordpress/?p=29647
And yes, I am familiar with Barron. Again, can you see error in his analysis of the data he cites?
You could try my approach – assume that the people making the recommendations, who have generally dedicated their lives to studying the topics at hand, are aware of the complexities of the literature and are not part of a conspiracy to kill large swathes of the population.
The alternative is to re-enroll in school, focussing on the biochemistry of the oxidation of atherosclerosis, get a Masters, then PhD, then do a post-Doc and at that point you might know enough to answer your questions with a degree of certainty you seem to be asking for. Science is complicated.
On a somewhat-related note, famed Egyptologist Mark Lehner had his studies funded by the Association for Research and Enlightenment, the foundation that exists to promote the ideas of Edgar Cayce, the sleeping prophet. Lehner went in as an explicit “skeptic” of the mainstream opinion, setting out to defend the lunatic fringe idea that Egypt was the legacy of Atlantis and other such nonsense. After dedicating years of his life to the mainstream ideas on the topic, he shelved his nonsense ideas and became a firm member of the establishment view.
All this to say – in an empirical area of scholarship, the mainstream view is usually right. The debates that exist between mainstream scholars are usually worth having. Crazy fringe proponents seem to think “mainstream” means “dogmatic” and “stupid”. Really it means “studying, in detail, a topic for a very, very long time to produce supportable conclusions”. Mainstream is the very opposite of stupid, no matter that some people are disappointed because it means there are no aliens, or the pyramids were built by men, or that you can’t pour butter on your cereal every morning. And chances are you won’t understand nitty-gritty detailed research without years of study. So maybe trust the experts.
@nwtk2007,
After checking out the link you gave, I came to the conclusion that Harriet should change the title to ‘Red Yeast Rice Poisons and Cholesterol’.
In other words just shut the heck up they are the doctors and must know what they are talking about? Looking back at the times when that to which you allude was the case and what suggesting the same would have been gives me pause to think about your suggestion.
At any rate, there is a huge debate as to the use of statins. Its not such a main stream idea, that lowering cholesterol is the end all of heart disease. Take away the promotion by big pharma for the sale of their statin drugs and there you have it.
As to what you say about mainstream, it is usually true. Take man-caused global warming for example. Or the belief in universal health care by the majority of folks in the world.
Heh, heh. I get called a white supremist, and then I get pointed to a link that is supposed to cast doubt on statins, and the title of the link calls statins “poisons.” nwtk2007, you truly are an idiot. The very fact that someone as ignorant as you can get a “license” to practice “chiropractic” demonstrates what a truly pathetic profession that is. The only debate on the use of statins is by anti-science pseudo-para-medical do-nothings like yourself, who have spent so much money on a completely useless education that actually left them net-negative in medical knowledge and now they are mad at the world.
BTW, I wanted to point out that I “appreciated” your “moving the goal posts.” In your most recent say-nothing post you phrased it as the “end all of heart disease.” No one ever made that claim, but you’ve now been backed into a corner, and instead of admitting that you were wrong and appreciating the fact you had the potential to learn something here, you are now going to move the goal posts and start trying to change the subject.
It’s actually not interesting that you are not only dishonest professionally, but dishonest personally too.
@nwtk2007,
Methinks you spend too much time feeding at such “mainstream” websites that you linked to. There has always been debate about statins and pretty much all meds. The goals of therapy have changed several times in the years that I have been in practice. If there were no side effects from statins, then everyone would be on them to lower the risk as much as possible. But such is not the case. The side effects, the law of diminishing returns for the risks and the costs, all make that impractical. That does not mean that chiros have anything better. Until you show us something else that works better than LDL lowering in preventing atherosclerosis, you can rage all you want and it won’t do squat.
The mainstream scientific consensus is indeed that man-made carbon emissions are altering climate world-wide, and the data is now strong enough that former scholarly skeptics have changed their mind. And pretty much the entire world has accepted the desirablility for universal health care – the US is an outlier. I’m not sure what point you’re making here. If you’re being sarcastic, that suggests you don’t think climate change is happening, or is man-made – and if that is the case then you are almost certainly wrong. If you’re being serious, then I’m curious why you’re bucking that trend when it comes to this issue in particular. And in both cases, there is a problem of arrogance – you think that your opinion is worth more than the opinion of thousands of other scientists who dedicate their lives to these topics. That seems foolish to me, like asking a bicyclist to repair your Prius (note – not a bicycle mechanic, just someone who rides a bike).
Iconoclasm has some merit in some situations – but they’re mostly in social, political and cultural circles. In science, iconoclasm is usually a waste of time unless you’ve got a viable alternative paradigm that accounts for more data than the current dominant one. So I’m not saying “just shut the heck up”, more that the strength of one’s argument is unrelated to the strength of one’s rhetoric. Calling statins “poison” is rhetoric, not argument, and I’m far more comfortable trusting hundreds of real experts than I am a small group who must publish on the internet.
Skeptical, have you noticed that your main response to most things is to insult the chiropractor. I probably had my masters in molecular biology before you got out of high school. Your continued antichiro response is a bit silly and continues to demonstrate huge bias such that you would turn down a life jacket and drown just because it was offered by a chiro. I do relish the silliness however. It continues to demonstrate the extreme self praise of the medical profession; an observation not un-noticed by many, many of your peers.
If you had read the article posted, it was an analysis of some data from JAMA on the debate about statins. Does the author’s point, based upon your reading and cognitive skills, have merit. For example, the author discusses one point of improvement with statins, “one person in every hundred seeing any benefit. Pitching that as a 44% improvement is number jerking, plain and simple!” He actually made several points of similar character. Being science based and objective, I would think that there could be some comment on his analysis, be it bogus or well thought out and why. Too much to expect? You are one of the experts, yes?
And I’m not sure what you mean by moving the goal posts or changing the topic. A sidebar comment is not a topic changer, although, if you are referring to my side comment on global warming then yes, Lawerence, it is obvious that there is strong evidence for global warming and it being a direct effect of man made effects. Not sarcasm but a subtle point to be sure. Maybe I should dress up everything with lots of smiley faces so you won’t think me arrogant or sarcastic. (This, by the way, IS sarcasm.)
@weing, this was an analysis of data taken directly from the JAMA. It sounded somewhat reasonable in a few ways I thought. Try not to assume that I am trying to argue as a chiro in their anti-drug/medications stance. I point my patients to meds daily and refer to MD’s/DO’s also for just such concern. Of course, I also do not treat heart disease.
Medical evidence is never as black and white as we would wish. The benefits of statins are not in question. Questions remain about the extent of benefits for individuals with various risk levels.
@nwtk2007,
“this was an analysis of data taken directly from the JAMA.” I am familiar with the discussion in JAMA, and it is nothing new. I can tell you, however, that the analysis in JAMA did not discuss statin poisons.
Calling it poison or not, this is the final conclusion:
“So what can we take away from this debate? Well, pretty much what I said at the beginning.
Although the medical community often seems to speak with one unified voice, in truth, it is often very divided on key issues. Unfortunately, the mainstream media does not do a good job of publicizing the “secondary” POV. This creates a huge misconception as to where the medical community stands on many issues.
Despite the stance of the AMA, there is actually a growing movement in the medical community for more natural — less interventionist — approaches.
And even though it seems as if the medical community is firmly behind statin drugs to lower cholesterol — even to the point of debating whether or not they should be added to the public water supply — there are a number of strongly dissenting voices…and a number of studies that back that dissent. Again, virtually all of the contrary studies are independent, whereas virtually all of the studies in support of statin drugs are industry sponsored. You can decide which you think are more credible.”
Actually, he makes a similar observation of bias as I have over the years. Is there bias in the data thus far?
I hardly think the medical community is seriously advocating puting statins in the water supply. That, along with calling statins “poisons”, is pure alarmist nonsense.
Is this what debates have come to? Someone posts a ridiculous, biased article, and expects people to go read it and give a crap what some random goober writes?
…
Congratulations on your masters, why did you waste that education by going into chiropractic? It’s like you canceled out so many years and actually regressed your knowledge base. Sad.
@nwtk2007,
“Although the medical community often seems to speak with one unified voice, in truth, it is often very divided on key issues. Unfortunately, the mainstream media does not do a good job of publicizing the “secondary” POV. This creates a huge misconception as to where the medical community stands on many issues.
Despite the stance of the AMA, there is actually a growing movement in the medical community for more natural — less interventionist — approaches.”
If that is what you got out of the debate, then I suggest you read the articles again in JAMA without the poison commentary that can poison your outlook. This is the debate I go through when I weigh the risks vs benefits of treating a patient in the intermediate risk category.
You know what’s scarry? Here we have nwtk2007, who has no understanding of the basics of hyperlipidemia, and yet he’s writing that he refers to MDs, etc, for health issues. But he has no understanding of these issues. So what patients is he actually referring? And how is he identifying these patients? This is one of the big issues with chiropractors seeing people that walk in off the streets. They have no medical knowledge, and once they’ve suckered some poor soul into their “care”, they then negatively influence the outcomes.
It’s very enraging.
Once again, I see your bias prevents you from objective comment regarding evidence or, in this case, interpretation of evidence.
Skeptical, your enragement is humorous to say the least. You’d be surprised how many very knowledgable folks are in the chiro profession doing what I have described what I do many times, yet you just let it slide from btwn your bitty little ears.
How could you possibly have gotten through med school with such a big old glitch in your thinking?
And thanks for the congrats on my masters work. I studied under guys who worked with Delbruck. That would be Max not Hans. Incredible insight into the genius of the fathers of molecular biology.
If there are knowledgeable folk in the chiropractic community, then you aren’t one of them. You don’t even know about the basics of treating hyperlipidemia. And that’s about as basic as it gets. I’m sure the people you “studied under” are disappointed that you studied science, then immediately turned to anti-science in your pursuit of professional quackery.
The mere fact that you consider my distaste for quackery as a “glitch in my thinking” further demonstrates that you are just nuts. Are you the same quack that previously said I must have been sexually abused as a child? And just recently you called me a white supremist? Boy, your stupidity is unparalleled. Go fix some subluxations, you mediocre fraud.
P.S., you’re a chiropractor. Haha!
I take it that you have no other crtisism of Jon Barron’s analysis of the debate on JAMA other than his referral to statins as poison. If not then I have made my point.
Skeptical, you poor thing, I simply said you sound like a white supremist, not that you are one. Your take on truth and reason seems a bit off as it is skewed by the “glitch” in your thinking, as I put it, which is your bias, not your distaste for quackery. My guess is that you would be a person who would vote for Romney, assuming you are a US citizen. His lack of truth and reason are astounding to be sure.
Oh, here’s another tid bit for you, the guys I was studying under were going to chiro’s long before I ever considered becoming one. And truly, they were of genius stature.
“I take it that you have no other crtisism of Jon Barron’s analysis of the debate on JAMA other than his referral to statins as poison. If not then I have made my point.” His analysis is not worth reading. I suggest that you read the original articles yourself.
Point made. Extreme bias prevents objective consideration of possible errors in mainstream practice. And, of course, that bias is effected by influences from outside sources such as big pharma and other money oriented entities to the exclusion of patient safety and well being; at least as far as the use of statins is concerned.
Pathetic
Like Fox news when presented with any facts that appear to contradict their views, they simple refuse to accept them with the emphatic statement,” I just can’t and won’t believe that. Are you sure you are not one of those straight chiropractors? Preacher? A sheep?
Like so many in the religious world; no need to question that which I already know so well. Love your response to people also. Probably the talk of the medical community, or so you might think. Har, Har. Love the smiley face.
You’re both trading insults and getting nowhere. Perhaps let this comment thread lapse, shall we?
nwtk2007, what facts contradict my views? Please re-read my posts and demonstrate any accepted “facts” that are contrary to what I wrote. Please. If you’re referring to the article that called statins poisons, then no, I did not read much further than the title. Why would I waste my time reading an article that starts off with a biased (and unsupported) title?
You were wrong – there is no big debate in the medical community on the usefulness of statins. Your selected quote form the article is also wrong. There is no discussion in the medical community to put statins in the water – that’s downright ridiculous. If a handful of doctors have “dissenting views” on statins, that simply means they are ignorant to the research behind them. If they are aware of the research and deny it, then they are idiots. People of any profession can be idiots, and there certainly are some doctors that are idiots.
PS, all the weird analogies, political references, etc, are irrelevant. We aren’t discussing any of those things. Please demonstrate that anything I wrote has an abundance of facts finding the contrary.
Since you won’t read the article then there is nothing to demonstrate as contrary as this is what I am referring to. However, perhaps you could respond to the following:
1. The discussion mentions data from three studies:
The WOSCOPS trial, which showed that treatment with 40 mg of pravastatin resulted in a 31% reduction in heart attacks and related deaths.3
AFCAPS/TexCAPS, which found that 20-40 mg of lovastatin reduced the incidence of first major coronary events by 37% and myocardial infarction by 40%.4
The Jupiter trial, which found that treating patients who had normal cholesterol levels but high C-reactive protein levels with 20 mg of rosuvastatin reduced the risk of myocardial infarction, stroke, and revascularization by some 44%.5
2. The author states as regards to the Jupiter study – “the Jupiter trial found is that whether you used the statin drug or not, your chances of having a heart attack were essentially the same: 1%. Or more precisely, if you take it out one more decimal place, that dramatic 44% improvement they talk about comes down to a drop from a 1.4% chance of having a coronary event to a 0.8% chance if you use statin drugs. You’re talking about maybe one person in every hundred seeing any benefit. Pitching that as a 44% improvement is number jerking, plain and simple!”
(The discussion involved cardiologists both for and against the use of statins.)
3. The author also states – “The pro cardiologists also suggested that a way to sort out who would be the best candidates for statin therapy is to offer them a coronary artery calcium (CAC) scan” but then “But are cholesterol and arterial calcification actually linked? Not necessarily, according to a 2006 study that found that calcium plaque continues to accumulate in coronary arteries even in the face of aggressive cholesterol reduction (-53% LDL cholesterol) with a statin drug.” The anti-cardiologists refute that.
Basically, the “pro-cardiologists” disagree with the “anti-cardiologists” in the need for statin use. Thus there is substantial disagreement among the doctors as to the benefits of statins versus risks. You will have to read their positions ot be able to comment either in agreement or not with either.
One of the most telling of the conclusions by this author is the following: “virtually all of the contrary studies are independent, whereas virtually all of the studies in support of statin drugs are industry sponsored.”
Don’t worry about it. You’ve already made up your mind enough that anything else said, even if by cardiologists in this discussion from JAMA who are opposed to the use of statins for patients with elevated cholesterol who are otherwise healthy, would not be worthy of review.
@nwtk2007
“Extreme bias prevents objective consideration of possible errors in mainstream practice.” You still don’t understand do you? Extreme bias is preventing you from objective consideration of possible errors in your understanding of what is written. Please read the original articles and not some biased commentary to find out what is really written and form your own opinion. As I said before, in patients of intermediate risk, I must do a very careful risk/benefit analysis. The articles are very good in pointing out what needs to be considered.
This thread was so helpful (particularly “International Network…” link, thanks Dr. Hall).
It was actually THIS issue that made me hate “modern medicine” etc. for so long until I found SBM (I thought you were “profoundly incompetent” and I railed against statins online, etc…I hate myself for being so arrogant/having no perspective).
Still I have a modicum of compassion for my former self…when you have zero science education some of these arguments from perceived authorities seem good and SCARY (for instance Ron Rosedale claims inhibition of CQ10 by statins trump everything else, or the advice of a chiro who was perceived as an authority when I was 20).
It’s too bad you don’t have a larger platform to help people, particularly young people who will use the internet to “research” their health issues and their parent’s health issues.
Thanks again, SBM. Ough! Ough! Ough!
Nwtk, I’m going to lunch. Will reply, I are exactly where you are 100% wrong. Do yourself a favor and google “Jupiter trial” and read at least the full abstract and you’ll see why what you (or that author) wrote is absolutely ridiculous. If you can’t figure it out by time I’m done eating then, well, yikes.
Weing – “Extreme bias is preventing you from objective consideration of possible errors in your understanding of what is written.”
Quite the contrary, I was hoping to hear some objective points of view about this authors analysis of the debate. I’m not arguing wither pro or con for statins and their use. I think the author has some good points which seem to be based upon the discussion between the cardiologists and the cited studies. Also, is it or is it not of interest that the industry sponsored studies are so different from the ones done by independents? Or is that also bunk?
For those who are seeking information yet find that some of the info garnered here on this site has some contradictory evidence not to hear those here’s take on it other than “the author said statins are poison so he must be a quack so don’t listen” is a bit weak.
@nwtk2007
“I was hoping to hear some objective points of view about this authors analysis of the debate.”
Here it is. The author’s analysis is biased.
Well, that just about says it all. Could the industry based studies also be biased also?
Nuff said.
Wallow in your own bias. Vote for Romney. (Not)
@nwtk,
Would you think an analysis of chiropractic that used the term crippling chiropractors to be anything but biased? I gave you my opinion of the original articles. I much prefer the source rather than looking through someone’s filters to form my own opinion.
@nwtk2007,
I am still waiting on you to point out anything that I wrote that you have “facts” that demonstrate the opposite.
Regarding your copy-pasted biased article:
That simply isn’t true. First of all, the JUPITER trial administered statins to people that had both normal LDL levels and elevated CRP levels (an inflammatory marker.) The trial found, specifically, that people given the statins experienced significantly fewer cardiovascular events and deaths. Just read the conclusion of the trial (below – again, just Google “jupiter trial”, the entire PDF is available to download):
JUPITER conclusion:
So, the biased authors “conclusion” is simply not true. Your chances of suffering from cardiovascular events are decreased by using statins. Furthermore, the implications of the JUPITER trial are interesting. These were people with LDL levels that are currently considered “healthy.” Read that again. These were in healthy people. We further reduced their LDL and CRP levels and they experienced even fewer cardiovascular events. This may mean that when the new ATP IV guidelines are released this year that the “healthy” level for LDLs may be even lower. In fact, I believe Dr. Nissen, author of Heart 411, hinted that more aggressive statin use will be recommended in the new ATP guidelines. I believe Nybgrus already said this, but it seems that with LDLs, there is no bottom number, meaning that we want them as low as possible. This trial hits that point home. We can further reduce the incidence of cardiovascular events by treating seemingly healthy people with a statin.
Any attempt to put a negative spin on that is pure dishonesty.
Regarding the coronary artery calcium score: irrelevant. The calcium score is not a good test. We don’t use it, and I did an informal poll and half my colleagues had not even heard of the test, and the others never use it. I don’t know much about it other than they do a CT scan of the chest and look for calcifications in the coronaries, and then add it up or something and use it to predict your risk for cardiovascular disease. I’m not even bothering reading the study your biased author mentioned that found no association between a patient’s calcium score increasing despite statin use, because it very well may be true. Simply put, we don’t regularly use the calcium score because it hasn’t been validated.
Let me repeat that. A high-risk calcium score is not an indication to start statins. There are no guidelines that say if a patient has a high-risk calcium score that a statin should be used. The vast majority of doctors do not send patients for calcium scores because the test apparently sucks.
The cardiologists I know will perform the test if a patient wants it, but I believe they counsel them that it’s not a very good predictor, and honestly I don’t think it would change the course of treatment (you certainly would not stop a statin if you had hyperlipidemia and a low-risk calcium score, likewise there is no indication to start a statin if you had normal lipids but a high-risk calcium score.)
If any doctor that reads or posts here regularly sends patients for a calcium score, please speak up, and explain what body of evidence is supporting that decision, because as far as I know, there isn’t much if any. I may simply be ignorant of it.
So, in your #3 point in the biased article, nwtk, the conclusion your author draws is simply invalid. He can’t claim that statins are useless because they didn’t affect the results of a test that is widely considered useless and the results of which likely will not influence outcomes. That’s like saying an antibiotic didn’t work because a patient’s depression didn’t improve.
Simply put, the “points” made by the author in that biased article are nonsense. He took things out of context, drew ridiculous conclusions, and made comparisons that simply demonstrate he has no idea what he is talking about. I hope this explains why none of us wasted our time reading the article. It’s pure nonsense.
By the way, next time, read the primary sources. Had you actually read the text of the JUPITER trial, instead of reading a ridiculous article that misinterpreted it, you would have saved yourself a lot of time and embarrassment.
Regarding the Jupiter study, you quote their conclusion but do not address the numbers; you simply assume their conclusion is valid. I read the original and to be honest, to say that such small decreases in cardiovascular problems with statin use outweighs the risks and deleterious side effects is disingenuous at best. The author of this study pointed to the very same numbers and made the same conclusion. The one example he cited, is essentially insignificant in its magnitude when compared to the risks; 1.4 per 100 person years down to 0.8 in otherwise healthy individuala with elevated LDL levels. The “con-cardiologists” came to this same conclusion and they point to a 2011 Cochran review to support their position. The con-cardiologists do, however, concede that the use of statins does reduce the chances of a second heart attack in patients who have experienced one already. It was also the Cochran folks who pointed out that the most of the other studies they reviewed were sponsored by pharm industry, yet it appears that examination of their own numbers doesn’t bear out their conclusions, at least according to the “con-cardiologists”. The author of this paper is more often than not, simply parroting the position of the con-cardiologists thus you are saying that it is not his conclusions that are invalid but theirs, the cardiologists.
You say he takes things “out of context” and drew “ridiculous conclusions”. Perhaps they con-cardiologists, per you, did. In fact, the con-cardiologists pointed out that the studies minimized the side effects of statins by eliminating those who reacted poorly to statins before the trials actually officially began. Selective population? Random? No.
I read the original Jupiter study and can see where this author and the con-cardiologists draw their conclusions. Did you? Now what I haven’t done is read the original debate out of JAMA to which this author is referencing. Perhaps he is lying about the con-cardiologists arguments against statin use, but I’m ready to give him the benefit of the doubt for now.
Basically, the use of statins in healthy folks, even with elevated LDL levels, is not indicated according to the con-cardiologists, when weighed against the various side effects of statins. Perhaps something without the same side effects would do the job of lowering LDL,but it is simply not conclusive that lowering LDLs in healthy individuals is of significant benefit.
BTW, in re-reading “point #2″, what the author did is simply idiotic. He took two values that were statistically significant and then simply delcared it insignificant. So we saw a drastic reduction in adverse cardiovascular events in HEALTHY people and the biased goober just says “well, it’s not that big of a deal.” Like hell it isn’t!
Honestly, nwtk2007, I’m surprised you weren’t able to read that article and not immediately identify all the BS in it.
I’m sorry, but you’re an idiot. I simply don’t have the patience to go back and forth with someone who keeps changing what they are arguing, who ignores mountains of data, and pulls things out of their rear. Your stupidity is exhausting.
BTW, I appreciate that you consider the “statins are poison” turd a “study.”
@nwtk2007,
“the use of statins in healthy folks, even with elevated LDL levels, is not indicated according to the con-cardiologists”
It’s not indicated according to the pro-cardiologists either. The consensus is that it should be prescribed based on the overall risk picture, not on an isolated elevation in LDL.
There is no disagreement about whether they work. The disagreements are opinions and personal value judgments based on how well they work in different groups and when the benefits outweigh the risks.
You are right to point out the difference between relative risk and absolute risk. For informed consent, patients should be told those numbers as well as the NNT and the NNH. Given the same evidence, some individuals will opt for statins while others will not.
Bottom line: statins work. Just not as well as some of the hype would have us believe.
Exactly Harriet. Statins lower blood LDL-C levels, no doubt. My initial point was not that statins don’t lower it but is lowering it also going to reduce heart disease enough to offset the side effects. Based upon the studies cited and discussed by the cardiologists in this article (not “study” skeptical) and further discussed by this author, it would appear that statins reduce heart attacks in folks who have had a previous heart attack but, in some opinions, including the con-cardiologists cited in this JAMA discussion, not significantly enough in healthy individuals even if they have elevated LDL-C, and that based upon “studies” cited by them and discussed by this author.
Also Harriet, what you refer to as hype, which it indeed is, to me, is reflected in the observation (if actually true) that the studies done by the pharm industry support the use of statins versus independent studies which apparently do not support so much use. I really have no data on that other than what the author has stated. It might or might not be true.
And skeptical, like I said, it was an article, not a study. There were studies cited within the article but the article itself was only an article/report/piece/etc.
I was unclear as to the use of patient versus patient-years, I believe it was. Stats are strange things sometimes. What is the difference between 0.8 and 1.4 patients or between 0.8 and 1.4 patient-years? When numbers like this come up, mathematicians and scientists tend to bring in significant figures and rounding errors inevitably pop up, especially in research. (Or it was person-years or man-years.)
@nwtk2007,
“My initial point was not that statins don’t lower it but is lowering it also going to reduce heart disease enough to offset the side effects.”
Then you made your point very poorly. That is not what I got from what you wrote. So far the studies show that the lower you bring down the LDL-C, the lower the risk of MI. The question then becomes is it worth it to lower the LDL-C in the individual before you with intermediate risk. You then have to weigh the risk of side effects of the medications vs the marginal benefit. I discuss these with my patients and sometimes we opt for meds, sometimes just for TLC. I also have patients that are high and some even very high risk and they do not tolerate any of the medications. I wish we had more options for them, as TLC is not enough.
@weing, that is because that was *not* his initial point. First his point was that something I stated was wrong (and nothing in my original post was wrong, it was nothing more than a collection of facts.) Then he wanted everyone to pay attention to a ridiculous article written by a know-nothing. Then his point was that there is a big disagreement in the medical community regarding the efficacy and use of statins, which again is wrong. Then he apparently argued against the idea that everybody should get statins, because he started mentioning a study in which otherwise healthy people — at least in terms of not having hyperlipidemia — received statins (and still noticed a statistically significant decrease in cardiovascular events and mortality – oh, but hold on, the chiropractor doesn’t agree with these findings!), despite the fact that no one in this thread was advocating giving statins to otherwise healthy people without concerning labs or risk factors. Now he’s agreeing with Harriet, and I can guarantee that the point she was making is infinitely far away from the point that nwtk2007 is apparently trying to agree with now. I’d bet that Harriet is saying that statins are fantastic, but they aren’t the wonder drug that some people make them out to be, whereas nwtk2007 is reading it as “statins have some minor efficacy, but may not be worth it in the end.” Of course, as always, he would be wrong.
In other words, he never had a point, and kept changing the subject until he argued a point that nobody was actually arguing against, and then believes that he somehow made sense.
skeptical, the gist of my original entry into this thread was to discuss the evidence and biochemistry related to the notion that elevated HDL-C cholesterol caused plaque formation or not. It was that simple since the mechanism is not clearly known and there are suggestions that it doesn’t in the scientific community as there are also some who think tht lowering doesn’t decrease heart disease. You were so intent on dissing the dumb chiro that you just couldn’t see it. And I only am agreeing with Harriet after further reviewing the discussion I cited more thoroughly and discussing it here. I wasn’t even responding I don’t think to anything you had posted at the time. The argument regarding the use of statins goes directly to the question of LDL-C’s role in heart disease.
You were blinded by the light. And so smart too. Really.
HDL’s now, eh? Please proof read your posts and try to be somewhat coherent. You have thoroughly wasted a lot of people’s time with your nonsense.
Obviously a mistake Ms Petunia. If YOU will reread my posts you might see that I am pretty on topic, for the most part. Read without the chiro cloud in your judgement, you’d probably be fine. Once again, its called bias.
Want to check my spelling, too? Enjoy.
nwtk has definitely shifted his stance and statements subtly without acknowledging it so that he is quite as wrong while still claiming to be right on his original point.
also, even the interpretation of the Jupiter study that nwtk is touting is inane. A reduction of coronary events from 1.4% to 0.8% in an otherwise completely healthy population is f&^$*@ing huge. Remember in my previous post I mentioed that “law of large numbers?”
We have 380,000,000 (or so) in this country. Lets say that 100,000,000 of them are otherwise healthy adults. And lets say we gave them all a statin. That means we would have prevented 600,000 coronary events. SIX HUNDRED THOUSAND in a HEALTHY POPULATION. So even THAT is pretty impressive. And nobody here is talking about giving statins to HEALTHY people.
I wish I had the time to actually go through all this and lay down a serious analysis that DavidRLogan would appreciate. But I simply am too busy doing actual medicine these days to take the time.
nwtk: “Obviously a mistake Ms Petunia”.
Yes, obviously, which is why SH asked you to please proof read your posts
I’ll juxtapose this another comment you made nwtk:
There’s obviously enough pedantic nit-picking to go around,* and focusing on that rather than points of substance may make people feel better but doesn’t advance any argument.
*and as a pedantic nit-picker, I demand my fair share
Yes I do enjoy the objectivity of many who speak out on this site. We could go on and on about typo’s but I’ll refrain.
Nygbrus, apply the big numbers analysis to the side effects and see what you come up with.
I will say,,however,, that I also refrain from like responses to much of the venom encountered here. There is much educational content to be garnered here. Its too bad more folks wont engage.
that’s called a risk benefit analysis. Exactly what we are talking about here. So lets break it down for you:
For those taking statin for 5 years to prevent heart disease you can break it down into those with known heart disease and those without.
For those without:
None were helped by preventing death
1.6% were helped by preventing MI
.4% were helped by preventing stroke
1.5% were harmed by developing diabetes
10% were harmed by muscle damage
So, NNT is 60 for MI and 268 for stroke and NNH are 67 for diabetes and 10 for muscle damage.
Conclusion: not worth the risk benefit.
For those with:
1.2% were helped by preventing death
2.6% were helped by preventing a second MI
.8% were helped by preventing stroke
.6% were harmed by developing diabetes
10% were harmed by muscle damage
So, NNT is 83 for saving a life, 39 for repeat MI, 125 for stroke and NNH is 167 for diabetes and 10 for muscle damage.
Conclusion: worth the risk benefit
And if you want to apply the law of large numbers again for that same hypothetical population, you would prevent 600,000 coronary events, have 10,000,000 people with muscle damage, and 150,000,000 with diabetes. Once again, for a HEALTHY population. Which nobody is advocating we summarily give statins to.
And I’ll take the time to illustrate your shifting goal posts and stance. At first it was that statins just don’t work because lipids don’t effect cardiovascular outcomes. Then it was that they do work, but that it isn’t worth targeting because lipids don’t have that much effect on outcomes. Now it is that the reduction is ONLY around 1%… oh, and in healthy people BTW. That, my friend, is goal post shifting.
After reading that ^^, does anyone actually oppose me calling this guy a moron?
Is it worth actually replying to a blithering idiot? Or does such a ridiculously stupid post warrant a legitimate response?
@SkepticalHealth – you probably don’t read my comments, but here goes.
My cognitive therapist recommended this book to me. Maybe it’s methods could help you free yourself from aggravating discussions with people who refuse to listen.
No offense intended on the title. I tend to think most normal people have their OCD moments.
http://www.amazon.com/Brain-Lock-Yourself-Obsessive-Compulsive-Behavior/dp/0060987111
@nybg, you left out the part that defines patient population in the second “analysis.” I don’t see how you came up with some of your numbers (150,000,000? That’s more than the people in your hypothetical population!) Also, let’s be realistic about “muscle damage.”
Very strange, man.
nygbrus – “At first it was that statins just don’t work because lipids don’t effect cardiovascular outcomes.”
Incorrect. It was simply a question regarding cholesterol, specificall LDL-C, as to how it causes, or its role in, plaque formation, if I remember correctly. If you could get off your pharm cheer leading, defensisve (I prescribe meds) mentality, you could have seen that.
As to goal posts, please, a discussion without some wavering of the outcome/topic/conclusion is really quite boring and in essence, settles nothing. I must say though, that it is quite amusing to see your high horses riled by simple questioning of your perspective such that you need to think into your preset conclusion to, at the very least, verify it for yourself. You both would be fun students.
Now skeptical, could you scan my post here for typo’s. My computer here won’t check spelling for me.
Nygbrus, I like your analysis, however, how could other cariologists have such a juxtaposed opinion on such an obvious conclusion, if indeed, you are correct?
@nwtk2007
Most folks won’t engage because they lack the knowledge or consider the issue more or less settled by the posts (which themselves are based on mainstream recommendations by genuine experts considering the totality of the evidence). I frankly don’t see the point in debating you over this topic for a couple reasons – I don’t know enough about statins, there’s an obvious consensus statins are helpful when used appropriately, and you seem more invested in and convinced by the statin denialism arguments (note deliberate link to AIDS and climate change denialism) than the mainstream one. If you’re genuinely concerned and interested in whether statins are beneficial, it’s going to take you years to absorb the information, and probably training you don’t have. So rather than arguing here on the basis of a bunch of people who lack credibility, you might be better off exploring your genuine concern in the form of another graduate degree, this time focussing on statins. Then you’ll really be in a position to know whether statins are useful or if the cholesterol skeptics are blowing smoke out of their collective asses.
@nybgrus,
No offense at all intended, but there seems to be a whole lot of issues with your last post.
I looked at the second link you provided, and reviewed the first 2 systematic reviews that it used for it’s data. Both of them found almost zero association between statin use and rhabdo (the so-called “muscle damage”), so I can’t begin to see where they got a ridiculous number of 1 in 10. The diabetes info was from a different study, which seems strange to include it as a factor in their little data pool. Combine that with the weird numbers you through out (150,000,000 with diabetes? lol. Only if you treated 5 earths worth of people.)
…
William, I don’t know what makes you think that I am debating about anything. I have asked more questions and asked for opinion regarding a JAMA debate than I have offered conclusions or arguments to the contrary of anything. Asking questions is not debate or argument. The folks here are essentially claiming to know and given their knowledge, it just seems natural to ask for their take on some issues. This assumption that I am anti-statin comes from where, I have no idea although I did point out that there are those who do not agree with the “consensus”, as you put it; for example the cardiologists in this JAMA debate. Not me but them although I do admit that I can see their point.
My last question was regarding that in particular; “how could other cariologists have such a juxtaposed opinion on such an obvious conclusion”. Do they represent “denialism” or do they have at least a modicum of a point in their position. Can the pro-statin group see any part of their argument as potentially valid?
And no offense, as has been pointed out on this site so often, blood letting was the consensus treatment for many things at some point in the past, not that this compares to the “consensus” you are referring to. When asked a question, don’t assume that there is an implied position or opinion behind it.
Also. when did I mention AIDS?
@MTR,
I find my OCD quite helpful in my practice.
nygbrus, of the 10% with muscle damage, which I would assume would be cumulative over years of statin use, will also develop concurrent kidney damage/accelerated decrease in kidney function?
You would assume wrong. Completely wrong.
In fact, elevated CK leading to any renal issues is extraordinarily rare with statin use. The “muscle damage” above is apparently nothing more than a possible myalgia, with absolutely no physical muscle damage occurring. It’s amazing that you’ll comment on these things without knowing anything about it.
@nwtk2007
It’s illogical to compare the “consensus” for blood letting to the consensus for using statins for so many reasons. Pick a better example next time.
Not trying to jump on the bandwagon arguing with you- I’ll leave that to those that are doing so.
The muscle damage numbers are suspect, IMO. Before starting patients on statin, I have them do a couple of squats and ask them how they feel. I use that as a baseline when they follow up.
Calling it “muscle damage” is just plain bizarre. Some people do complain of muscle pains after starting statins, but they rarely have elevated CKs indicating actual muscle damage. (Some people get a baseline CK before starting a statin, but I don’t see where that’d really change the course of treatment, because you’re not going to routinely measure CK levels while asymptomatic, and if you had untolerable myalgias you’d just DC the medication.) If a patient cannot tolerate statins, then stop them. It’s very simple. To calculate it as if you’re causing “muscle damage” is just wrong. Sure, we can be semantic about it all day long, but let’s be realistic.
@weing – “I find my OCD quite helpful in my practice.”
yeah, then it’s not an obsessive compulsive disorder, it’s the obsessive compulsive advantage.
skeptical – “It’s amazing that you’ll comment on these things without knowing anything about it.”
Do you know what a “?” is? You just can’t read anything without getting off on some incorrect assumption. It is truly a sad state to be in, really. Of course I did leave out the word “they” and it should have read, “…will they also develop….” In your bitty brain it must be such a huge disconnect to actually communicate in a rational way. Bottom line is that is wasn’t a comment, but an inquiry. I’m sorry but you are just too stupid. Highly intelligent I think but at the same time, stupid. I still think you must think you’re some kind of “House” doctor. Into the hydrocodone are ya?
Actually, you’re right, I shouldn’t have added that last dig at you when you incorrectly predicted the clinical course of “muscle damage.” I apologize.
Not to argue, but I didn’t predict anything either. If there is muscle damage its just a logical next question as to the level of muscle damage and the potential sequence of events that can entail. If, as you have said, the muscle damage is, essentially, not muscle damage per se, then it is not a concern.
Anecdotally, my dad as a mild form of Parkinson’s and was on statins for about two years. His condition worsened, especially in regions of his body not previously effected by the Parkinson’s. His doctor took him off the statins over a year ago now and those regions have returned to full function. Additionally his cholesterol levels have not become elevated in the mean time. (The Parkinson’s effected his hands from about the elbows down. His leg strength and control became significantly impaired as he was given medications including the statins but has since returned to normal with the discontinued use of the statins.)
nwtk:
“Do you know what a “?” is? ”
A question mark can mean many things.
In my experience in reading and commenting on blogs over the past few years it can mean:
1) The person is ignorant of the topic and is genuinely looking for information.
In my experience this is rare. I mean, if I want to find out about a topic I research it and study it and then, if I don’t understand something, I ask someone who I think has some expertise. There are some who are genuinely looking for information but the tone of their post is usually neutral or subdued and they are appreciative of any understandings given.
2) The person is playing devils advocate.
I have done this on occasion when I believe something should be true but I can’t completely convince myself that it is. I then think of all the reasons why it may not be true that I have no answer for and play devils advocate amongst those who agree with my point of view. I have learnt some important lessons this way.
3) The person pretends not to have a view but his whole focus is to trip up those with the opposing view.
I have never done this. I think it is dishonest. You should give your view up front and take whatever criticism comes your way. Then you can legitimately challenge the opposing view. It’s the only genuine way to learn anything. Put your view out there and be prepared to have it demolished.
My assessment is that you fall into category 3.
It’s a falsely safe position because you can fall back to the “I’m only asking questions” gambit but most posters see right through that ploy.
…of course, I apologise if I have mischaracterised you.
If we were debating and not discussing, I could agree with a little of what you have said. But I have offered no counter argument on any topic other than to bring in other information; in this case the link to the article in which the author discussed the debate between cardiologists in JAMA. You can go back and re-read what I have posted and see for your self. If I am in an argument or debate, which I have on this site, then I am pretty direct and almost never ask a question. I would also think that the questions I have raised would be raised by others as well.
There has always been a general defensive yet elitist attitude from the commentors on this site which is amusing but not a difficulty. It leads to misunderstanding many statements, even among themselves.
@nwtk2007, I would challenge the idea that you “brought in information.” You linked an extraordinarily biased article that drew incorrect conclusions (“600,000 lives? Irrelevant!”) and honed in on non-issues (ie, in reality, nobody is seriously suggesting putting statins in the water supply, and nobody is seriously advocating treating perfectly healthy people with statins, however, it is possible our current understanding of “healthy” may be setting the bar too low, I’ll be genuinely interested to see the new ATP IV guidelines!) In fact, if we consider the word information to mean “something that was not previously known to the person” (Richard Dawkins uses this definition in a fantastic article he wrote) then you did not bring any information to this discussion. That is, I don’t think you “enlightened” anyone with anything that you wrote.
You may be interested in learning more about statins, and if you are then that is fantastic, but I would not go as far as to say that you actually contributed anything beneficial, unless we consider the possibility of other posters learning from people answering your “questions.”
@BillyJoe, I whole-heartedly agree.
The article I cited brought in the debate and a discussion of its contents. I’m wondering why the debate in JAMA hadn’t been brought up by anyone else. Given that, you could have gone to the actual debate and referred to that specifically. Having read it, there are some very interesting comments from the cardiologists about the use of statins to treat cholesterol alone in otherwise healthy individuals.
By the way, you referring to something as biased is truly the pot calling the kettle black.
@ BillyJoe – spot on.
Really fellas, you have a nice little fraternity but I can’t imagine why you would think I might want your approval such that you would dish out the BS so thickly. If I were ya’ll, I’d just try to keep up.
@skeptical:
You are right… my math was incorrect. Between my clinical duties and my two research projects I just put in 120+ hours in the last 7 days and had three 21 hour days in a row, so my apologies. I still try to read a bit here to keep my sanity, but my last post was indeed not up to my usual standard.
I also agree that the numbers cited were a bit… off… for exactly the reasons you claim. My point in them was that even in such a dire sort of “worst case” scenario calling it “muscle damage” and all that, it still meets the bar for being useful. It wasn’t my most eloquent or hard hitting riposte though, I’ll admit.
And now that I actually have some time off and managed to sleep for 13 hours straight, I will go off to have a nice brunch with my lovely blonde rocket scientist and leave y’all to continue the great statin debate of 2012.
Ta ta!
I bet you can’t wait to be done. By the end of 3rd and 4th year I was so sick of being a student. But you’ll still look back at those 21 hour days fondly. It’s a whole different world when you’re actually responsible for what happens. My worst was 30 hour days (…) on our OB rotation (full day, plus having to stay for the didactic lecture that took the whole next AM, of course only if your OB call day fell on the day before the once a week lecture.) But the sheer fun of med school made it all worthwhile.
Which residencies are you going to apply for? Are you going to be doing the upcoming match?
Actually I am rather enjoying it! Plus, “done” is a very relative term. I will be learning, reading, and improving every day till I die so I don’t ever see myself as “done.” Though having a paycheck… and especially an attending’s paycheck… would be nice at some point. LOL.
I managed to avoid those crazy 30 hour days because of call and didactics. Partly by luck (holidays fell right when it should have happened to me) and partly because I saw no point in hazing myself when I could read the lectures on my own after I had slept so I managed to slink away
But yes, OB was the one that has a penchant for that for some reason.
As for which residency… I am 95% certain I will do internal medicine and then 95% certain I will do a pulmonary critical care fellowship afterwards. There is some wiggle room in case a decide anesthesia or emergency medicine is more my thing, but that is unlikely though I am trying to keep an open mind. There is also a little wiggle room once I get to residency and maybe discover something else catches my fancy even more. But my girlfriend is an aerospace engineer and we both kind of (i.e. she really, really and I am just one really) want to go to outer space, so pulmonary CC seems like a good choice for being the medical officer on a space mission. Thankfully I will know how to do reiki, acupuncture, and chiropractic so that we can still save lives with the limited resources available in space :-p
I won’t be in the upcoming match but in the one after that. Because I am on a southern hemisphere schedule, my year starts in January and ends in November, so I will be done with Year 3 in November, apply halfway through my 4th year, and then hopefully match after I graduate a year from this November. There will be a lag time between finishing med school and starting residency during which I plan to interview, wrap up any research projects I have going on, and then ultimately travel for a couple of months after I match to unwind and recoup before getting back into it.
Conveniently the Jupiter trial has an update in the lancet:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61190-8/fulltext
The risk of diabetes from statin use is basically none in people without risk factors. It its 28% in people with. Even then cardiac event prevention still outweighs diabetes risk.