Statins

[Ivor the Engineer]

What fraction of people should be on statins? Everyone over the age of 30? 40? 50?

Has science found a fundamental flaw in human biochemistry that needs to be fixed with a drug, or are statins a treatment for a problem that is usually of the individual's own making and is within their control through other means?

[kellyb]

Well, evolutionarily, we are more or less expendable after age 40 or 50 or so...

Reading glasses are somewhat similar.

I don't know if statins are overprescribed or not, though. But it wouldn't surprise me if people just started breaking down a lot at a certain age, and some problems could be remedied with drugs.

[lionking]

Sorry, can't be bothered looking it up. What are statins?

[Soapy Sam]

http://www.medicinenet.com/statins/article.htm

Drugs that are supposed to reduce cholesterol, helping you to die for other reasons.

[lionking]

Oh okay. My mum was probably on them and if so they worked well (she's over 70). As for me, when I was told that I was over the recommended level, I changed my diet.

[Soapy Sam]

Me too.
I take the statins religiously and have increased my chocolate intake 300%.
And I'm still alive, too!

[Ivor the Engineer]

Well, evolutionarily, we are more or less expendable after age 40 or 50 or so...

Reading glasses are somewhat similar.

I don't know if statins are overprescribed or not, though. But it wouldn't surprise me if people just started breaking down a lot at a certain age, and some problems could be remedied with drugs.

I'm not sure you can equate the problem(s) that lead to the need for reading glasses with the behaviour that lead to high cholesterol. Isn't high (LDL and low HDL) cholesterol more frequently related to poor diet and a sedentary lifestyle than bad genes? If so, don't statins become more like drugs of convenience than need?

[Ivor the Engineer]

Me too.
I take the statins religiously and have increased my chocolate intake 300%.
And I'm still alive, too!

You have made my point perfectly!;)

[frankvan]

I don't thik it's an either/or type question. There are drugs that claim to lower LDL's and raise HDL's but are not statins. Some foods, like oatmeal, make similar claims. But even though high cholesterol levels pose health threats, it also appears that some high cholesterol foods, like egg yolks, are recommended in a healthy diet in moderation. As has been pointed out, we do tend to crap out gradually past a certain age, so it is best not to abuse our selves any more than necessary, at any age.

[sophia8]

I'm not sure you can equate the problem(s) that lead to the need for reading glasses with the behaviour that lead to high cholesterol. Isn't high (LDL and low HDL) cholesterol more frequently related to poor diet and a sedentary lifestyle than bad genes? Not always. I have hypothryroidism, which produces high cholesterol levels. In spite of being on a low-fat, near-vegan diet, my cholesterol level is still between 7 and 8 (which is too high, according to my doc). Having had side-effects from statins in the past, I don't want to go on them again, but I may have to. I'm waiting for the result of my latest cholesterol test; if the level hasn't gone down, then it's the statins.

[Ivor the Engineer]

Not always. I have hypothryroidism, which produces high cholesterol levels. In spite of being on a low-fat, near-vegan diet, my cholesterol level is still between 7 and 8 (which is too high, according to my doc). Having had side-effects from statins in the past, I don't want to go on them again, but I may have to. I'm waiting for the result of my latest cholesterol test; if the level hasn't gone down, then it's the statins.

That's why I put the phrase "more frequently" in. If you have a condition that is beyond your control, then drugs are a reasonable course of action.

However, are statins being give to people who just don't want to exercise more, loose weight and cut back on the fried / fatty food?

FYI: I think the target for total cholesterol is below 4mmol/l, with LDL of 2mmol/l. IIRC, it is actually the ratio of HDL to total cholesterol which is a better measure of risk than total cholesterol.

[Soapy Sam]

Not always. I have hypothryroidism, which produces high cholesterol levels. In spite of being on a low-fat, near-vegan diet, my cholesterol level is still between 7 and 8 (which is too high, according to my doc). Having had side-effects from statins in the past, I don't want to go on them again, but I may have to. I'm waiting for the result of my latest cholesterol test; if the level hasn't gone down, then it's the statins.

C'moan, hen. We're Scottish. We're SUPPOSED tae huv high cholesteroil. My mammy even gave me that cholesteroil tae drink when ah wiz a wean!

[patnray]

I'm not sure you can equate the problem(s) that lead to the need for reading glasses with the behaviour that lead to high cholesterol. Isn't high (LDL and low HDL) cholesterol more frequently related to poor diet and a sedentary lifestyle than bad genes? If so, don't statins become more like drugs of convenience than need?
Kellyb wasn't equating the problems, merely pointing out that problems that occur late in life, like heart disease and stiffening of the lens, are not subject to natural selection because they occur after sexual maturity and thus do not prevent the traits from being passed to future generations.

[Bikewer]

I've been taking them for about 15 years. At age 48 or so, I had my first cholesterol screening; through the roof. Over 300 and that with a pretty modest diet and tons of exercise. (I was riding over 100 miles a week at the time)
Exercise and a low-fat diet was not going to cut it; this was a hereditary condition. The doc put me on Lipitor and reading went into the normal range in a few weeks.

Due to the vagaries of our wonderful HMO and drug pricing, I've changed three times over the years; Lipitor to Zocor to the generic Simvastatin and now with Zetia added.

Keeps my readings in the normal range.....

Apparently, there are a variety of other benefits from the class of drugs as well, it may play a role in reducing systemic inflammation.

[Schneibster]

There are a lot of folks of Northern European extraction who have high cholesterol not because they eat bad stuff, but because their bodies make it, specifically their livers. I'm one of them, which is how I know about it. It doesn't matter what I eat or how much I exercise.

Be careful stereotyping, Ivor. There is a significant number of people who aren't sedentary and eat good diets and still have high cholesterol.

[casebro]

Plus the stress connection. My cholesterol was 440 once. A bad disc was giving me sciatica to the point of causing a limp.

Anyway, I figure that statins actually work via lowering inflammation. Cholesterol is merely a confounding. Since aspirin works as well as statins at preventing heart attacks, but both together only work 20% better than either alone, then 80% of what statins do is the same thing that aspirins do.

Then, I believe that a major source of inflammation is sub-clinical food allergies. They don't show up as antibodies in allergy tests, but do cause enough inflammation to have long term consequences.

Hmmm, or was the sciatica causing enough inflammation to make my cholesterol leap? No, aspirin does not lower cholesterol, only inflammation. Plus lessen clotting.

[Ivor the Engineer]

There are a lot of folks of Northern European extraction who have high cholesterol not because they eat bad stuff, but because their bodies make it, specifically their livers. I'm one of them, which is how I know about it. It doesn't matter what I eat or how much I exercise.

Be careful stereotyping, Ivor. There is a significant number of people who aren't sedentary and eat good diets and still have high cholesterol.

I suppose it was inevitable that some people who have a medical/genetic condition that raises their cholesterol level in-spite of them leading a healthy lifestyle are going to see my point of view as stereotyping. I shall therefore be more explicit:

I have no problem with people who have tried to lower their cholesterol through lifestyle changes first and found that they cannot for reasons out of their control.

What I do have a problem with is people being given statins before they have attempted to alter the behaviours which are the likely cause for them having high cholesterol. This is mainly because those same behaviours lead to other chronic health problems, such as obesity, high blood pressure, diabetes, etc.

[Ivor the Engineer]

C'moan, hen. We're Scottish. We're SUPPOSED tae huv high cholesteroil. My mammy even gave me that cholesteroil tae drink when ah wiz a wean!

Land of the deep-fried Mars bar:)

Average life expectancy in Glasgow for males 68. Government proposes to raise retirement age to 69.

[Mashuna]

I have no problem with people who have tried to lower their cholesterol through lifestyle changes first and found that they cannot for reasons out of their control.

What I do have a problem with is people being given statins before they have attempted to alter the behaviours which are the likely cause for them having high cholesterol. This is mainly because those same behaviours lead to other chronic health problems, such as obesity, high blood pressure, diabetes, etc.

I can agree that the whole 'prevention is better than cure' approach is the best one to take. I'm not sure what you're suggesting though. Are you advocating witholding treatment until people have made these efforts, or was it more of a 'I don't have any sympathy for. . .' kind of point?

[Ivor the Engineer]

I can agree that the whole 'prevention is better than cure' approach is the best one to take. I'm not sure what you're suggesting though. Are you advocating witholding treatment until people have made these efforts, or was it more of a 'I don't have any sympathy for. . .' kind of point?

The former - I think statins should not be offered to people who refuse to alter the aspects of their lifestyle that are likely to be causing them to have elevated cholesterol levels.

At least in the UK, GP's appear to be handing statins out like smarties at the moment. Some doctors have proposed everyone over the age of 50 being put on them, making it sound like high cholesterol is an unavoidable consequence of getting old!

Are we building up problems by allowing people to use statins to stave off an early heart attack or stroke, while maintaining a lifestyle that will lead to many other chronic conditions?

Is that what the NHS's role will be in the future - giving the population drugs to combat the effects of their ignorance and stupidity?

It sounds like it to me, given the projection that over half of the UK's adult population will be obese by 2050 if the current trend continues.

[Quavergirl]

I'm a cardiologist and use statins daily. There is a tremenous amount of data supporting their use (i.e. less dead bodies) and good documentation of their known side effects and therapeutic limitations (which I respect). More about that later if you are interested. Personally, I tailor the use of these drugs to each and every different patient sitting in front of me. A doc has to "adapt" guidelines--that is, be a "doctor", not just parrot the party line.*

I find the the development of statins fascinating. There was a little girl named Stormy Jones. She developed throat pain at age 8--thought to be a sore throat initially. Turns out she was having a heart attack. She was missing both copies of her LDL receptor gene in her liver; she had homozygous familial hyperlipidemia (about 1:1,000,000 incidence). Total cholesterol in these cases run in the 600-800 (sorry--US units) range and the patients develop physical signs of the cholesterol burden in their bodies. She was studied by some guys from Texas (Brown and Goldstein) They later won a Nobel Prize for ID'ing the LDL receptor. Stormy, however, died. Her doctors reasoned that a liver transplant would "cure" her LDL receptor problem, but they also needed to transplant her heart which had been destroyed by multiple heart attacks. They tried a heart-liver transplant but she did not survive.

Statins were thus created to force the liver to create more LDL receptors. They work great on heterozygous familial hyperlipidemia (missing one LDL receptor gene, incidence about 1:500 !!, LDLs run about 180-220) because there is at least one allele present to make more LDL receptors.

You can just wave a statin in front of those people and drop their LDLs in half. Patients with different genetic and non-genetic contributors to elevated LDL respond in a variable fashion--hence the need to customize therapy.

LDL reduction is not the entire story of why people die less as well as have fewer heart attacks and strokes while on statins. There are pleotropic effects of these drugs (anti-inflammatory perhaps?) that come into play and reduce "hard" events (We cardiologists are simple folk--we count the hard events like death, heart attack and stroke. Other fields are too soft--for example, an oncologist claiming that a cancer has a 30% "response" rate to a drug--what does that mean?? Does the patient live one day longer??) Anyway, LDL reduction alone does not account for the rapid drops in hard events seen in the big trials (tens of thousands of patients).

Q

*I also have a kid with autism, so my "faith" in popular medical science interpretation has been deeply shaken--more than every before I review the medical literature with the intent of weeding out the politics. Medicine is as subject to fads and mistaken "consensus" as is every other field (remember low-fat diets?)

[Darat]

The former - I think statins should not be offered to people who refuse to alter the aspects of their lifestyle that are likely to be causing them to have elevated cholesterol levels.

At least in the UK, GP's appear to be handing statins out like smarties at the moment.

...snip...

Where do you get that impression from? There are quite comprehensive guidelines about who a Doctor should prescribe statins to (off the top of my head if I recall correctly it's people that are calculated to have a 1 in 5 chance of a heart attack or stroke within the next 10 years).

And I do not want to have a health service that would (if it followed your views) decide that people should die or be left severely disabled for the rest of their life simply because they didn't quite manage to lose the "X" pounds indicated by your guidelines.


ETA: UK Guidelines (http://www.uclh.nhs.uk/NR/rdonlyres/0A09D988-0CAB-4CFC-BB58-BEC5212F6D19/34496/statinprescribingguidelines1.pdf):

...snip..

The new NICE guidelines (January 2006) propose statins for secondary prevention
of cardiovascular disease and primary prevention for individuals with ≥20% 10 year
cardiovascular risk. They also state that the statin with the lowest acquisition cost
be used. Initial estimates are the guidelines make 1 in 4 of the population aged 30
to 75 eligible.

...snip....

[Soapy Sam]

There are a lot of folks of Northern European extraction who have high cholesterol not because they eat bad stuff, but because their bodies make it, specifically their livers. I'm one of them, which is how I know about it. It doesn't matter what I eat or how much I exercise.

Be careful stereotyping, Ivor. There is a significant number of people who aren't sedentary and eat good diets and still have high cholesterol.

Bingo! My family for example. Mind you, this is not an excuse to stop exercising.;)

Land of the deep-fried Mars bar:)

Average life expectancy in Glasgow for males 68. Government proposes to raise retirement age to 69.
You have to die of something. It may as well taste good.:D

[Quavergirl]

To address the OP:

Withholding therapy due to disapproval of lifestyle is unethical. And it's a slippery slope that I (and I suspect most doctors) are not willing to step on. If third party payers/governments don't want to PAY for therapy to ameliorate the "wages of sin" that is an entirely different issue. But as a physician, I'm not a judge. I'm here to treat people with diseases/injuries (however acquired)

I'm pondering the ramifications of judgmental medicine. I'm not willing to:

1. Withhold statins or diabetic medication from obese/sedentary people
2. Withhold antibiotics from the septic woman after a botched abortion
3. Withhold surgery from the person shot while robbing a bank or shooting someone
4. Withold lung cancer surgery from the smoker
5. Withhold anti-HIV drugs from persons engaging in anal sex
6. Withold STD therapy from the child molestor
7. Withold birth control in an unmarried woman
8. Withold skin cancer surgery in the sun-worshipper
9. Withold breast cancer therapy in the HRT taker
10. Withold cervical cancer therapy in the prostitute
11. Withold prostate cancer therapy in the celibate
12. Withold surgery from the crashed drunk driver
13. Withold surgery from Darwin award nominees
14. Withold treatment from the unvaccinated

I'm certainly not shy about advising/lecturing/berating people into trying to make lifestyle changes, but I have to treat regardless. We do not know as much as we think we do about the etiology of disease. There is always marked uncertainty as to the exact contribution of lifestyle to certain problems; disease happens to the best of us. Disease is not an accurate judge of character.

Q

[Ivor the Engineer]

<snip>

And I do not want to have a health service that would (if it followed your views) decide that people should die or be left severely disabled for the rest of their life simply because they didn't quite manage to lose the "X" pounds indicated by your guidelines.

<snip>

Everyone is going to die of something. In the UK, it is likely to be quite a long and costly affair too. Do statins increase the cost to the health service by letting people who would have died in their 50's of a heart attack, linger on with ever increasing health problems because they have failed to address basic issues, constantly brought to their attention, such as weight, smoking, diet and exercise? Is there anything people are expected to take responsibility for with regards to their health?

On the other issue I brought up: Given the number of people with cholesterol levels above the recommended 4 mmol/l, is this a fundimental flaw with human biochemistry? Or is it a flaw with modern diet and activity levels? Are statins tackling the ultimate cause of the problem for most people? If not, what other problems are going to occur by ignoring the root cause(s)?

[Ivor the Engineer]

To address the OP:

Withholding therapy due to disapproval of lifestyle is unethical. And it's a slippery slope that I (and I suspect most doctors) are not willing to step on. If third party payers/governments don't want to PAY for therapy to ameliorate the "wages of sin" that is an entirely different issue. But as a physician, I'm not a judge. I'm here to treat people with diseases/injuries (however acquired)

I'm pondering the ramifications of judgmental medicine. I'm not willing to:

1. Withhold statins or diabetic medication from obese/sedentary people
2. Withhold antibiotics from the septic woman after a botched abortion
3. Withhold surgery from the person shot while robbing a bank or shooting someone
4. Withold lung cancer surgery from the smoker
5. Withhold anti-HIV drugs from persons engaging in anal sex
6. Withold STD therapy from the child molestor
7. Withold birth control in an unmarried woman
8. Withold skin cancer surgery in the sun-worshipper
9. Withold breast cancer therapy in the HRT taker
10. Withold cervical cancer therapy in the prostitute
11. Withold prostate cancer therapy in the celibate
12. Withold surgery from the crashed drunk driver
13. Withold surgery from Darwin award nominees
14. Withold treatment from the unvaccinated

I'm certainly not shy about advising/lecturing/berating people into trying to make lifestyle changes, but I have to treat regardless. We do not know as much as we think we do about the etiology of disease. There is always marked uncertainty as to the exact contribution of lifestyle to certain problems; disease happens to the best of us. Disease is not an accurate judge of character.

Q

Statins provide a risk reduction. There are often other personal behaviour modifications that would offer similar risk reductions. Before a person gets statins, they should have adjusted their behaviour to minimize their risk. If after doing this they still have an elevated cholesterol level, then treatment with statins should begin.

Everyone should be treated for acute and chronic illness, without prejudice. Not everyone should be provided with risk-reducing drugs if they refuse to take basic steps to reduce the risk first.

[Graham Jackman]

Everyone is going to die of something. In the UK, it is likely to be quite a long and costly affair too. Do statins increase the cost to the health service by letting people who would have died in their 50's of a heart attack, linger on with ever increasing health problems because they have failed to address basic issues, constantly brought to their attention, such as weight, smoking, diet and exercise? Is there anything people are expected to take responsibility for with regards to their health?

On the other issue I brought up: Given the number of people with cholesterol levels above the recommended 4 mmol/l, is this a fundimental flaw with human biochemistry? Or is it a flaw with modern diet and activity levels? Are statins tackling the ultimate cause of the problem for most people? If not, what other problems are going to occur by ignoring the root cause(s)?

A major problem with relying on cholesterol measurement is that shows a wide normal variation and is only poorlky correlated with risk, unless you happen to have familial hypercholesterolaemia. The major risk factors for cardiovascular disease are; family history, smoking, diabetes, hypertension and obesity. I may be overweight, but not obese and have no other risk factor than a cholesterol about 7 mmolar. I refuse to take statins because I do not see them offering me any major benefit and side effects of the treatment are common.
On an earlier comment about egg yolks. They do contain cholesterol, but studies have shown that cholesterol intake does not affect plasma cholesterol unless it exceeds the amount normally synthesised. This equates to about 1.5g or 6 eggs a day. What does influence cholesterol measurements is intake of saturated fats. As part of a study I ate 4 eggs a day for a month and I'd happily do it again.

[Mashuna]

The former - I think statins should not be offered to people who refuse to alter the aspects of their lifestyle that are likely to be causing them to have elevated cholesterol levels.


Well, Quavergirl's already said it better than I'm about to, but would you extend this line of thinking to, say, smokers with lung cancer?

[Schneibster]

Not everyone should be provided with risk-reducing drugs if they refuse to take basic steps to reduce the risk first.You have ignored ethical problems that would land you in prison, or else with your pants sued off, in any liberal democracy on the planet. Welcome to the real world.

[Ivor the Engineer]

Well, Quavergirl's already said it better than I'm about to, but would you extend this line of thinking to, say, smokers with lung cancer?

Everyone should be treated for acute and chronic illness, without prejudice. Not everyone should be provided with risk-reducing drugs if they refuse to take basic steps to reduce the risk first.

Does that answer your question?

To put it another way, I don't expect the NHS to provide me with a helmet when I hurl myself down an icy hill on two planks of wood.

[Ivor the Engineer]

You have ignored ethical problems that would land you in prison, or else with your pants sued off, in any liberal democracy on the planet. Welcome to the real world.

What ethical problems? I'm not saying people should not have access to statins, just that a state funded system should not pay for them if the individual is not going to take basic precautions themselves first. If they want to lead a lifestyle that puts them at increased risk and use statins to mediate that risk, then they should pay for the drugs, not the state.

[Schneibster]

What ethical problems? I'm not saying people should not have access to statins, just that a state funded system should not pay for them if the individual is not going to take basic precautions themselves first. If they want to lead a lifestyle that puts them at increased risk and use statins to mediate that risk, then they should pay for the drugs, not the state.OK, what's your fool-proof treatment for people who overeat, so they can get the statins they can't afford to pay for? You haven't thought your way through this. It's bad ethics. You can't withhold medical treatment, and it doesn't matter if the problem is self-inflicted. It's against the Hippocratic Oath.

[Ivor the Engineer]

OK, what's your fool-proof treatment for people who overeat, so they can get the statins they can't afford to pay for? You haven't thought your way through this. It's bad ethics. You can't withhold medical treatment, and it doesn't matter if the problem is self-inflicted. It's against the Hippocratic Oath.

Is overeating a disease? If an individual has a disease then they should be treated for that disease, no matter what they have done to get it.

Self-inflicted high cholesterol is not a disease. It is a risk factor in getting a disease.

[Schneibster]

Sorry, Ivor, not interested in the death penalty for fat people.

[Soapy Sam]

Not even if they wear Lycra leggings? You can take tolerance too far.

Schneibster- the NHS system provides drugs like statins free only to those qualified for financial reasons to get them. (The elderly, unemployed, pregnant, the likely categories.)
Although I have been prescribed statins by my NHS doc., I do have to pay for them , as an employed person.
Incidentally- do US doctors actually swear an oath of any sort on qualifying? I'm told they don't here.

[Ivor the Engineer]

Not even if they wear Lycra leggings? You can take tolerance too far.

Schneibster- the NHS system provides drugs like statins free only to those qualified for financial reasons to get them. (The elderly, unemployed, pregnant, the likely categories.)
Although I have been prescribed statins by my NHS doc., I do have to pay for them , as an employed person.
Incidentally- do US doctors actually swear an oath of any sort on qualifying? I'm told they don't here.

When you say 'pay', do you mean the full price, or the standard prescription charge?

[Ivor the Engineer]

Sorry, Ivor, not interested in the death penalty for fat people.

Neither am I. That is why they should be helped to get their weight down, exercise more and have a healthier diet. What they should *not* be given is little magic pills that allow them an excuse to carry on eating too much, having crap diets and taking little exercise simply because one measurement of their biochemistry has dropped to within the "normal" range.

If there was a drug that smokers could take to reduce their likelihood of getting lung cancer, should a public health system subsidize it?

How reckless to individual health does an behaviour have to be before a state health system should stop using resources to help mediate the risk from that behaviour?

[Schneibster]

Helped how? What do you suggest we do that we're not already doing? The information is out there; freedom implies that people make their own choices. All we can do is tell them the consequences of their behavior; it's up to them to do something about it. Withholding medical treatment is not an ethically justifiable behavior modification option. Neither doctors nor health plan administrators would make good Orwellian fat police. And the consequences here are death or lifelong disability. That's the death penalty for fat people, and nothing you've said so far sways my opinion.

I'll also point out that if someone doesn't die, they are permanently disabled and require long term treatment that costs a lot more than the pills would. Not to mention being incapable of holding a job and therefore eligible for free treatment, instead of helping defray the costs. So, the question is not, would you rather pay for pills for fat people or not, but, would you rather pay a little for pills for fat people, or a lot for treatment of those people after they have heart attacks? Leaving aside consideration of their welfare, it's STILL not justifiable.

[SYLVESTER1592]

I don't want to kick anyone in the shins (:boxedin: expecting Linda flaming anytime now :D) , but internal medicine ( except infectious disease) is in most cases postponing the inevitable. Most typical diseases in internal medicine are crippling chronic diseases and are treated in a way that plays the numbers. You use treatments that have shown to reduce risk or improve the outcome in large populations. You don't necessarily cure people in the sense that the underlying disease is eliminated, but lengthen the patients lives and hope they can function better during this increased survival period. If you are successful, the patient dies at an old age from something else entirely without ever having experienced serious problems from the chronic disease. This is effectively a cure of the problem (not the disease).

The addition of statines is exactly that, playing the numbers, reduce the risk factors. If you have an illness that is related to a high cholesterol, the addition of statines can be part of the treatment regimen.

Many drugs have this idea in mind. All of these other drugs are usually covered for the appropriate indication (as long as the effects have been proven).

Since there is no wonder-pill that cures all underlying disease or a magic drug that brings the dead to life, a cure in the form of medication is in most cases some form of symptom and risk control.

(Cowardly hiding from the flame war :scared:)

SYL :)

[Ivor the Engineer]

Helped how? What do you suggest we do that we're not already doing? The information is out there; freedom implies that people make their own choices. All we can do is tell them the consequences of their behavior; it's up to them to do something about it. Withholding medical treatment is not an ethically justifiable behavior modification option. Neither doctors nor health plan administrators would make good Orwellian fat police. And the consequences here are death or lifelong disability. That's the death penalty for fat people, and nothing you've said so far sways my opinion.

I don't know why you keep on saying I'm advocating withholding treatment.:confused:

What aliment do statins treat?

How is anything I have said stopping people who want to take statins buying them?

As for what we should be doing, how about tax on (fast) food which does not meet certain standards? E.g. Make a burger and chips more expensive than the healthier options on the menu?

I'll also point out that if someone doesn't die, they are permanently disabled and require long term treatment that costs a lot more than the pills would. Not to mention being incapable of holding a job and therefore eligible for free treatment, instead of helping defray the costs. So, the question is not, would you rather pay for pills for fat people or not, but, would you rather pay a little for pills for fat people, or a lot for treatment of those people after they have heart attacks? Leaving aside consideration of their welfare, it's STILL not justifiable.

No one dies or is disabled by high cholesterol. It is a risk factor for conditions that do kill or disable.

People trade risk. If they know statins keep their cholesterol level ok, they will compensate.

There has been a report released recently which concludes that if the current trend continues, over half of the adult population in the UK will be obese by 2050.

How much is that going to cost the NHS to treat? Obviously they will all be on statins for life from the age of 35, diabetes medication from the age of 40, having their first hip replacements at age 50...

[Ivor the Engineer]

Here's an interesting presentation on cholesterol and heart disease:

http://uk.youtube.com/watch?v=i8SSCNaaDcE#GU5U2spHI_4

[Schneibster]

I don't know why you keep on saying I'm advocating withholding treatment.:confused:

What aliment do statins treat?High cholesterol, a proven risk factor for expensive and debilitating heart disease.

How is anything I have said stopping people who want to take statins buying them?If they don't have the money to buy them, you propose not to pay for them with national healthcare. I think this is short-sighted, and a penalty on people whose appearance you don't like. I'm sorry you don't like fat people, but I don't think they deserve to die because you don't like them. I also think you haven't addressed my point about the eventual costs of the disease being higher than the cost of treatment. Which means you're weaseling when confronted with your own prejudices.

As for what we should be doing, how about tax on (fast) food which does not meet certain standards? E.g. Make a burger and chips more expensive than the healthier options on the menu?I have no opinion on that; it's not the subject under discussion.

No one dies or is disabled by high cholesterol. It is a risk factor for conditions that do kill or disable.Correct, and if it is not treated, those conditions will occur, kill, disable, and cost lots more money than treating it would have. It's neither ethically nor financially justifiable.

People trade risk. If they know statins keep their cholesterol level ok, they will compensate.You're making judgments that involve other peoples' lives and health, based on your own prejudices. You've lost a lot of cred with me over this. I think you'll lose plenty with other people too. You are attempting to justify withholding inexpensive treatment for a chronic condition that leads to expensive disability if untreated, on the grounds that the chronic condition is due to some moral fault of the people experiencing it, which isn't even scientifically true, much less ethically justifiable. You haven't got a leg to stand on, and the fact you haven't provided a lick of evidence to support your assertions, and have ignored evidence that in fact the proposed action to save money will actually wind up costing more, shows it.

There has been a report released recently which concludes that if the current trend continues, over half of the adult population in the UK will be obese by 2050.So? What do you want, kill them all if they're fat? Release the food police?

How much is that going to cost the NHS to treat? Depends on whether they pay for statins, or for heart surgery, doesn't it?

Obviously they will all be on statins for life from the age of 35, diabetes medication from the age of 40, having their first hip replacements at age 50...Again, what do you want to do? Withholding treatment for a chronic condition ain't it.

[Soapy Sam]

When you say 'pay', do you mean the full price, or the standard prescription charge?
The latter.
(I also do take my general health a bit more seriously than I may have implied.)

ETA- While prescription of statins is one attempt at proactive medication which I applaud in the sense that it beats waiting till someone is actually ill, there are two aspects which trouble me. I think Ivor shares my concern.

1. There is something of a shotgun blast approach. I have privately asked eleven patients of the medical practice with which I'm registered. All are aged 45-60. All of them are either taking statins or have refused- but all were encouraged by the practice to take them. Yet when I asked a friend in another town, he polled seven friends and relatives in the same age range at his doctor. Not one had been offered or asked about statins. A tiny survey, I realise, but a curious discrepancy.
2. The attitude I suggested earlier, that people think "being on statins" is a licence to eat high cholesterol foods and stop exercising. (Honest, I was kidding about myself, but the thought does occur when I wander past the chocolate shelf).

In the UK in the last 15 years, the overall shape of the population has changed. The teenagers and sub-teens in particular are fat- sloppy and lacking any sort of muscle tone. They have bellies like poisoned dogs - often pointedly on display below tiny tops. They don't think they are fat, any more than we thought we were skinny. But many of the kids I was at school with, now in their fifties, are STILL slim. But their kids and grandkids are not.
Fast food, TV Dinners, shopping by car , 2 litre bottles of sugary carbonated drinks and " special value packs" (read "BIG") of high fat snacks.
At the same time, children have adopted a much lower energy lifestyle. It's just not cool to run around playing "tig" any more. Looking cool, wearing designer gear, hanging out at the mall and playing video games are the main pastimes. Static stuff.
I remember a few fat kids at school in the 60-70s, but they were notable as exceptions. Now they are , if not quite the norm, then at least extremely common.
We do need to change attitudes on this. If people get the idea they can live this way and stay healthy by taking pills, well, I can't see that as positive at all.
It's kind of ironic that the fat explosion is happening just as Brits are kicking the tobacco habit in ever greater numbers.

[Ivor the Engineer]

Schneibster:

I'm researching this at the moment and will be presenting what I've found here in the near future.

And I really don't know why you think I hate fat people. People can do exactly what they want to their bodies as far as I'm concerned. But I do expect them to pay for measures that mediate the risks they take.

I have serious doubts over the supposed cost benefits to the NHS by increasing the number of people on statins.

How many days longer does an individual live if they are on statins for "high" cholesterol?

What diseases are made more likely by low cholesterol?

Are you sure that statins help reduce the risk of CHD through their cholesterol lowering effects?

[Darat]

Ivor - as far as I was aware the claims for statins and the reason they are prescribed is to reduce the likelihood of serious cardiovascular problems. Consider a case of someone you consider has not "done enough" to reduce their cholesterol (and you will not prescribe them a statin) drops down in the street from a stroke.

Will you now refuse the ambulance, the emergency treatment (the very expensive immediate post-stroke medication), the months of recuperative treatment and then the long term disability payments because they can no longer work?

[Ivor the Engineer]

Ivor - as far as I was aware the claims for statins and the reason they are prescribed is to reduce the likelihood of serious cardiovascular problems. Consider a case of someone you consider has not "done enough" to reduce their cholesterol (and you will not prescribe them a statin) drops down in the street from a stroke.

Will you now refuse the ambulance, the emergency treatment (the very expensive immediate post-stroke medication), the months of recuperative treatment and then the long term disability payments because they can no longer work?

For the third(?) time:

No, all people should be treated without prejudice. I.e. no matter how they have lived their life up to the point they collapse, they should get exactly the same level of care as anyone else. This includes (but is not limited to): fat people, thin people, rapists, murders, lawyers, politicians and JREF forum moderators who keep on arguing with me;) Hell, even Linda too.:D

As for the cost benefit of statins to the NHS by avoiding treatment for strokes and heart attacks, especially the mass prescribing of them to groups at ever decreasing risk, I am not yet convinced they will bare the fruit many claim they will.

Then you have the side effects, claimed to be extremely rare. But is that because many are put down by doctors as related to age or other unrelated factors, when in fact they are related to the statins? E.g., there has already been a proposed link between low LDL and increased risk of Parkinson's disease.

[Schneibster]

Schneibster:

I'm researching this at the moment and will be presenting what I've found here in the near future.I'm sure you'll find some woo study that says something bad about statins. Whatever.

And I really don't know why you think I hate fat people. Because it's generally agreed that when someone shows prejudice against a class of people, they hate them, whether they admit it or not.

People can do exactly what they want to their bodies as far as I'm concerned. But I do expect them to pay for measures that mediate the risks they take.Similarly, you are free to make whatever assumptions you care to about how people get certain conditions, no matter whether they have anything to do with reality or not. But I expect you to accept the fact that if you refuse to examine those assumptions, then others will identify you as prejudiced. That is, after all, what it means; you've pre-judged.

I have serious doubts over the supposed cost benefits to the NHS by increasing the number of people on statins.And I have serious doubts as to the objectivity of someone who casts aspersions on treatments tested under double-blind protocols without having evidence in hand to support their assertions. Having to go looking for such evidence says that you have no idea right now whether it's true or not; and having had heart surgery myself, and seen the bills, and having paid for statins for several years, and seen the bills for that as well, I'd say that I have a good deal more knowledge on this subject than you do, or are likely to have anytime soon. And quite frankly, no matter how prejudiced you may be, I hope you never gain that knowledge the way I have.

How many days longer does an individual live if they are on statins for "high" cholesterol?The question is, how often do people who have high cholesterol have heart attacks and strokes when they take statins, vs. when they do not? And the answer is, less often- that's why doctors prescribe them.

What diseases are made more likely by low cholesterol?What does that have to do with anything? And what makes you think it has any effect at all, other than on women who are pregnant or nursing? As far as anyone can tell, those are the only people who risk anything by the clinical levels statins reduce cholesterol to.

Now, no doubt, if statins were used to reduce cholesterol to unusually low levels, some problem might result. But regular cholesterol testing ensures that that doesn't happen.

Are you sure that statins help reduce the risk of CHD through their cholesterol lowering effects?I don't know what CHD is. The connection between statins and lowered risk of heart attack in people with high cholesterol is documented in double-blind testing. Whether that's because they lower cholesterol, or some other factor, is speculative, but the connection between taking them and lowered risk is well documented.

[casebro]

Here's the data as I see it: The longest term studies of statins are five years. During that time, the control group had a 7.5% death rate. The Statin group had a 5% death rate. That is a 33% improvement. Oh, they average 1 year longer. Sounds good, eh? But lets look at the same specs like this: 2 1/2% means that ONE out of forty people live longer. Forty people times five years is 200 patient years of treatment. For one patient year of life extension. That means that for you to live to be 76, instead of dying at 75, your great-great-great-grandfather had to start taking the statins in 1825.

But so far as the health care system goes, it means that they will delay paying for each angioplasty ($12,000 to $30,000) or a CBG surgery ($40,000-$60,000) for several months. The profits they make by investing the money in the mean time is what makes those huge businesses profitable. Especially when the patient pays the brunt of the drug cost. My HMO, even with Medicare Part D drug coverage, means I pay about 80% of generic drug costs.

Of course, for those with genetic hypercholesterolemia, your mileage may drastically improve. Hmmm, I wonder, if those few patients with genetic hypercholesterolemia were eliminated from the statin studies, if the drug would show no benefit for the rest of us? But the genetic hypercholesterolem-ics would show great improvements? Pharmacogenetics, when are you going to get here? Hmmm, not as long as the patient is paying for the drug, or 80% of it...

[Mashuna]

If there was a drug that smokers could take to reduce their likelihood of getting lung cancer, should a public health system subsidize it?



Yes, especially if it means they can save money on expensive cancer treatments and surgeries by giving out a cheaper drug as a preventative.

[Darat]

For the third(?) time:

No, all people should be treated without prejudice. I.e. no matter how they have lived their life up to the point they collapse, they should get exactly the same level of care as anyone else. This includes (but is not limited to): fat people, thin people, rapists, murders, lawyers, politicians and JREF forum moderators who keep on arguing with me;) Hell, even Linda too.:D

As for the cost benefit of statins to the NHS by avoiding treatment for strokes and heart attacks, especially the mass prescribing of them to groups at ever decreasing risk, I am not yet convinced they will bare the fruit many claim they will.

Then you have the side effects, claimed to be extremely rare. But is that because many are put down by doctors as related to age or other unrelated factors, when in fact they are related to the statins? E.g., there has already been a proposed link between low LDL and increased risk of Parkinson's disease.

Sorry I just can't follow your reasoning - you wish to deny people statins because they haven't done enough in your opinion to lower their cholesterol because it is expensive to the health service, yet we know that without statins a significant number of those people will suffer from serious cardiovascular disease yet you are quite happy to pick up the cost of treatment for that.... something doesn't seem to add up. You are willing to pay for the expensive treatments even though it is "self inflicted" but not willing to pay for the cheaper treatments because it is "self inflicted".

From what I've read the cost of a generic statin prescription for a patient for a year is around £25 (http://www.guardian.co.uk/medicine/story/0,,1979274,00.html). If every man, woman and child in the country was prescribed statins tomorrow it would cost us £1.5 billion a year, heart disease alone costs us £29 billion a year (http://news.bbc.co.uk/1/hi/health/4764891.stm).

Lets be more realistic, say all 50 year olds and above were prescribed statins so that would be around 20 million people in the UK, that would be a cost of £500,000,000 or half a billion, and if that only reduces the cost to the UK of heart attacks by 5% it would save the country almost one and a half billion net cost benefit of almost a billion pounds. (I really do hope I've got all my noughts correct else I'm going to look like rather silly!)

So even putting aside anything about ethics or morality prescribing statins (if they do as claimed) is a financially sound policy for the NHS.

[Ivor the Engineer]

Sorry I just can't follow your reasoning - you wish to deny people statins because they haven't done enough in your opinion to lower their cholesterol because it is expensive to the health service, yet we know that without statins a significant number of those people will suffer from serious cardiovascular disease yet you are quite happy to pick up the cost of treatment for that.... something doesn't seem to add up. You are willing to pay for the expensive treatments even though it is "self inflicted" but not willing to pay for the cheaper treatments because it is "self inflicted".

My opinion is that we are creating a sick society, which if things carry on the way they are going, will have almost every member of it taking medication for something. Statins look like being the first of the mass medications or ‘supplements’ huge numbers of people will urged to take. What will be the next risk the pharmaceutical companies are going to help us reduce in the easiest way possible? Why bother living a healthy lifestyle when the NHS will provide you with pills to help you avoid the long-term consequences of your actions? In the future will it even be possible to be classed as healthy unless you are taking risk-reducing medications? E.g., Americans are urged to achieve an LDL below 2mmol/l and total cholesterol below 4mmol/l. How many people would need to be medicated to achieve those figures?

From what I've read the cost of a generic statin prescription for a patient for a year is around £25 (http://www.guardian.co.uk/medicine/story/0,,1979274,00.html). If every man, woman and child in the country was prescribed statins tomorrow it would cost us £1.5 billion a year, heart disease alone costs us £29 billion a year (http://news.bbc.co.uk/1/hi/health/4764891.stm).

Lets be more realistic, say all 50 year olds and above were prescribed statins so that would be around 20 million people in the UK, that would be a cost of £500,000,000 or half a billion, and if that only reduces the cost to the UK of heart attacks by 5% it would save the country almost one and a half billion net cost benefit of almost a billion pounds. (I really do hope I've got all my noughts correct else I'm going to look like rather silly!)

So even putting aside anything about ethics or morality prescribing statins (if they do as claimed) is a financially sound policy for the NHS.

The total drug budget for the NHS is ‘only’ £8bn./year So statins, even if only prescribed for over 50’s, statins would be over 6% of the total drug budget. Factoring in other costs and people on statins, that's about £1bn./year spent on drugs and other treatments so people can have a reduced risk of CHD while maintaining an unhealthy lifestyle that increases the risk.

A flaw in your reasoning is assuming that all those people who avoid heart attacks do not end up suffering from other chronic illnesses that need even more expensive drugs and treatment. E.g., how much does cancer cost to treat? How much do hip replacements cost? How much does diabetes (and related complications) treatment cost? The list is endless.

For the NHS to slow the increase in spending the population needs to become healthier, not more medicated.

[Darat]

My opinion is that we are creating a sick society,

...snip...

Yet today before we have this widespread prescribing of statins that you think will create a "sick society" the cost of cardiovascular disease is put at £29 billion. It would seem the "sick society" is already here.

[Ivor the Engineer]

Yet today before we have this widespread prescribing of statins that you think will create a "sick society" the cost of cardiovascular disease is put at £29 billion. It would seem the "sick society" is already here.

And dishing out ever more statins (about 4 million take them at the moment in the UK) is not going to make it go away.

ETA: From a pharmaceutical company point of view, it may even be worth giving them away, since people will live long enough to get cancer, which as we all know, is where the real money is.

[Darat]

Sorry your reasoning is now totally beyond me - you are now seeming to say it is bad to keep people alive because that will mean they only get more expensive illnesses! So you are saying that "people who do not adjust their lifestyle should be allowed to die even if we have a cheap effective treatment that would keep more of them alive".

Which ever way you slice it Ivor you are saying that treatment should be withheld based on whether people live a lifestyle you approve of.

[casebro]

Soooo, if our average age of deaths from heart disease is 75, but our average age of death from cancer is 60, then if we cure heart disease then we will all die younger from cancer? ;)

Anyway, statins have been on the market for 20 years now. 40% of us still die from heart disease. It just takes a couple months longer. Remember, 2 1/2% of us life a year longer, thats NINE days each averaged out amongst us all. At what cost? At $50/month, for 5 years, thats $3,000 for NINE days. Each. Or $333 per day.

Can our economies support $333 per day for each of us? Where will the money for shiney new cars come from? Or to buy Britney's newest album?

[Ivor the Engineer]

Sorry your reasoning is now totally beyond me - you are now seeming to say it is bad to keep people alive because that will mean they only get more expensive illnesses! So you are saying that "people who do not adjust their lifestyle should be allowed to die even if we have a cheap effective treatment that would keep more of them alive".

Which ever way you slice it Ivor you are saying that treatment should be withheld based on whether people live a lifestyle you approve of.

What I'm saying is ultimately you don't keep them alive or healthy for longer because their risk of other diseases is increased by their unhealthy lifestyle. All you end up doing is trading one cause of death for another, with minimal reductions in morbidity or mortality.

[Ivor the Engineer]

Here's some enlightening (if somewhat depressing) reading on the risk factors associated with heart disease and their increase over time in the UK and the rest of the world:

http://www.heartstats.org/temp/2006spwholespdocumenths2hs.pdf

ETA: Not the latest one! This one is:

http://www.heartstats.org/uploads/documents%5C48160_text_05_06_07.pdf

[krazyKemist]

Well, anyway, cholesterol is very badly absorbed in food. Most of our cholesterol comes from our own biosynthesis, that's why statins are so efficient and low-cholesterol diets often fail. Some foods can lower LDL levels, tending to act like statins (like grapefruit which contains a weak P450 inhibitor).

And it kind of get on my nerves earing people talk about "cholesterol" rather than LDL. We synthesize cholesterol because we need it (it is the precursor of all sex hormones, corticoids, and is essential in cell membranes, more so in the skin). LDL (Low-density lipoprotein) is the transport form that seem to cause problems when in too high concentrations.

Another thing is that atherosclerosis is actually a degenerative disease, with a strong inflammatory component, and that LDL levels are a very poor predictor for it. The mayor of my city, a lady of about 70 years old, died very suddenly of heart attack with perfect LDL level and blood pressure. She was also quite active and was not obese.

the Kemist

[Darat]

Here's some enlightening (if somewhat depressing) reading on the risk factors associated with heart disease and their increase over time in the UK and the rest of the world:

http://www.heartstats.org/temp/2006spwholespdocumenths2hs.pdf

ETA: Not the latest one! This one is:

http://www.heartstats.org/uploads/documents%5C48160_text_05_06_07.pdf

I take it from reading that report that you will also be advocating that if people don't change their lifestyle by moving up the socio-economic ladder they also shouldn't be given statins..... ?

[juniper_ann]

Isn’t this really the “abstention-only” argument, with the target changed from “horny teenagers” to “fat slobs?” After all, if you give the kids condoms they’re only going to use them, but if you don’t, they’ll all be models of purity who arrive at their wedding nights unsullied and completely free of babies and diseases.

It might be a nice theory, but this here is the real world where some people can’t or won’t or don’t know how to lose weight. This is the world where people are fat because they have low literacy and little access to health information, or because the traditional food of their homeland is laden with excess calories, or because they have to work two jobs and literally have no time for exercise, or maybe because they’re depressed and use food as a comfort item but don’t feel up to exercising.

No study has ever successfully shown a four-year maintenance of weight loss. Certainly, it’s happened outside of studies, so it’s possible, but it’s not that simple.

[Ivor the Engineer]

I take it from reading that report that you will also be advocating that if people don't change their lifestyle by moving up the socio-economic ladder they also shouldn't be given statins..... ?

I don't know where you've got that idea from:confused:

Are you saying there is no way for an individual that is classed in a lower socio-economic group to reduce their risk of CVD without either (a) taking statins or (b) getting richer and/or more posh?

Next you'll be saying smoking is one of the few pleasures they have in life...

BTW, if they can afford to buy cigarettes they can afford to buy statins too.

[Darat]

I don't know where you've got that idea from:confused:

Are you saying there is no way for an individual that is classed in a lower socio-economic group to reduce their risk of CVD without either (a) taking statins or (b) getting richer and/or more posh?

Next you'll be saying smoking is one of the few pleasures they have in life...

BTW, if they can afford to buy cigarettes they can afford to buy statins too.

No what I am saying is that being of a lower social-economic group increases your risk so applying your reasoning you would have to say to the patient "you have an increased risk of cardiovascular disease because you are in a 'lower' socio-economic group, unless you make lifestyle changes to change your group we won't prescribe you with statins".

It is exactly the same as saying:

"you have an increased risk of cardiovascular disease because you are overweight, unless you make lifestyle changes to change your weight we won't prescribe you with statins".

[Michael Redman]

Do statins increase the cost to the health service by letting people who would have died in their 50's of a heart attack...Preventing people from dropping dead at the height of their economic productivity is probably worth the additional cost. Economically, you're best off keeping people as healthy as possible as long as possible.

The idea that people who are overweight should simply get in better shape instead of taking statins presents an unrealistic false choice. If the only reason to keep from giving people statins is to inspire them to get in shape out of fear of death, I don't think that's a very good reason. People who need statins should take statins. People who need to lose weight should lose weight. Separate issues.

(I do agree, though, that it might be beneficial to find a way to charge people for lifestyle choices that put a larger burden on the public and/or reward people who are less risky. Nothing motivates like the pocketbook.)

[Ivor the Engineer]

Isn’t this really the “abstention-only” argument, with the target changed from “horny teenagers” to “fat slobs?” After all, if you give the kids condoms they’re only going to use them, but if you don’t, they’ll all be models of purity who arrive at their wedding nights unsullied and completely free of babies and diseases.

That's an interesting point. In the UK we have a problem with teenage pregnancies and STD's are on the rise, even though condoms have probably never been more available. What has changed is the belief that these are things that will screw up your life in some way. E.g., HIV is not seen as a death sentence any more.

It might be a nice theory, but this here is the real world where some people can’t or won’t or don’t know how to lose weight. This is the world where people are fat because they have low literacy and little access to health information, or because the traditional food of their homeland is laden with excess calories, or because they have to work two jobs and literally have no time for exercise, or maybe because they’re depressed and use food as a comfort item but don’t feel up to exercising.

No study has ever successfully shown a four-year maintenance of weight loss. Certainly, it’s happened outside of studies, so it’s possible, but it’s not that simple.

I agree the root causes are hard to tackle and probably cost more in the medium to long term to solve. But I see the alternative (most of the adult population being medicated) as even worse.

[Ivor the Engineer]

No what I am saying is that being of a lower social-economic group increases your risk so applying your reasoning you would have to say to the patient "you have an increased risk of cardiovascular disease because you are in a 'lower' socio-economic group, unless you make lifestyle changes to change your group we won't prescribe you with statins".

It is exactly the same as saying:

"you have an increased risk of cardiovascular disease because you are overweight, unless you make lifestyle changes to change your weight we won't prescribe you with statins".

You mean like being black makes you more likely to be of low IQ?

That's why they're called individual risk factors.

[Ivor the Engineer]

Preventing people from dropping dead at the height of their economic productivity is probably worth the additional cost. Economically, you're best off keeping people as healthy as possible as long as possible.

The idea that people who are overweight should simply get in better shape instead of taking statins presents an unrealistic false choice. If the only reason to keep from giving people statins is to inspire them to get in shape out of fear of death, I don't think that's a very good reason. People who need statins should take statins. People who need to lose weight should lose weight. Separate issues.

(I do agree, though, that it might be beneficial to find a way to charge people for lifestyle choices that put a larger burden on the public and/or reward people who are less risky. Nothing motivates like the pocketbook.)

I don't think they are separate issues. People often have high cholesterol (and immediate health problems) because they have poor diet, little exercise and are overweight or obese. If they are smoking as well, isn't it rather futile treating them for high cholesterol? I wonder how much the problems caused by obesity and smoking, excluding CVD, cost the economy and health service?

[Michael Redman]

I don't think they are separate issues. People often have high cholesterol (and immediate health problems) because they have poor diet, little exercise and are overweight or obese. If they are smoking as well, isn't it rather futile treating them for high cholesterol?
Only if you make the assumption that the benefits of statins do not accrue in people who have those other risk factors. If that were true (which seems unlikely), then you would be correct, it would be pointless to give statins to those people. But if you are incorrect, then, indeed, they are separate issues.

I wonder how much the problems caused by obesity and smoking, excluding CVD, cost the economy and health service?Although they do suggest other areas in need of attention, those costs are irrelevant to the decision of whether to give people statins when the drugs are indicated. The only question that matters there is whether the cost of giving them statins will be recouped on lowered healthcare dollars and increased worker productivity.

[Ivor the Engineer]

Only if you make the assumption that the benefits of statins do not accrue in people who have those other risk factors. If that were true (which seems unlikely), then you would be correct, it would be pointless to give statins to those people. But if you are incorrect, then, indeed, they are separate issues.

Although they do suggest other areas in need of attention, those costs are irrelevant to the decision of whether to give people statins when the drugs are indicated. The only question that matters there is whether the cost of giving them statins will be recouped on lowered healthcare dollars and increased worker productivity.

There has been a recent article in the Lancet that indicated that statins do not significantly alter when a person dies, only what they die of (http://www.telegraph.co.uk/health/main.jhtml?xml=/health/2007/07/02/hdrug102.xml).

Your point is valid, if the cost of the statins is recouped in income tax, national insurance payments and savings for the health service by avoiding more expensive treatment related to CVD, then they probably pay for themselves, possibly many times over. I'm not sure they do though. Adding up all the costs for treatment of cancer, diabetes, hip and other joint replacements, etc. that unhealthy people are going to need, do they really reduce expenditure on healthcare?

[Darat]

You mean like being black makes you more likely to be of low IQ?


No idea, since I don't know if that is true or not (although I suspect it isn't).


That's why they're called individual risk factors.

And for most individuals being of "lower" socio-economic group increases their individual risk factors of developing cardiovascular-vascular disease just like for most individuals being overweight increases their individual risk factors. Sorry Ivor but your reasoning regarding this issue is just all over the place, it's not consistent (and doesn't seem to be based on any evidence).

Your reasoning boils down to "we won't provide an effective medication to you because you don't live an approved lifestyle".

[Darat]

There has been a recent article in the Lancet that indicated that statins do not significantly alter when a person dies, only what they die of (http://www.telegraph.co.uk/health/main.jhtml?xml=/health/2007/07/02/hdrug102.xml).

Your point is valid, if the cost of the statins is recouped in income tax, national insurance payments and savings for the health service by avoiding more expensive treatment related to CVD, then they probably pay for themselves, possibly many times over. I'm not sure they do though. Adding up all the costs for treatment of cancer, diabetes, hip and other joint replacements, etc. that unhealthy people are going to need, do they really reduce expenditure on healthcare?

There is a contradiction in what you are putting forward - if statins do not alter significantly when you will die than there will be no additional costs for treatments that people will need because they are living longer so we can ignore that.

Your point that "unhealthy" people will need additional treatments because of their general state of health is not an argument against prescribing statins to people who don't live the lifestyle you deem "acceptable", it is an argument for saying we should encourage people to live in a way that we know will result in a general better state of health.

[Ivor the Engineer]

<snip>

Your reasoning boils down to "we won't provide an effective medication to you because you don't live an approved lifestyle".

My reasoning boils down to if you are choosing to behave in a way that increases your risk of CVD, you should pay for the risk reduction of CVD provided by statins. For example, the NHS could charge cost price or above to those who choose to take statins as opposed to alter their behaviour, just as the government puts tax on cigarettes.

[Ivor the Engineer]

There is a contradiction in what you are putting forward - if statins do not alter significantly when you will die than there will be no additional costs for treatments that people will need because they are living longer so we can ignore that.

That assumes that what they end up dying of costs the same or less than treating CVD.

Your point that "unhealthy" people will need additional treatments because of their general state of health is not an argument against prescribing statins to people who don't live the lifestyle you deem "acceptable", it is an argument for saying we should encourage people to live in a way that we know will result in a general better state of health.

Making people pay for their quick-fix drugs encourages them to live in a way that we know will result in a general better state of health.

[Darat]

My reasoning boils down to if you are choosing to behave in a way that increases your risk of CVD, you should pay for the risk reduction of CVD provided by statins. For example, the NHS could charge cost price or above to those who choose to take statins as opposed to alter their behaviour, just as the government puts tax on cigarettes.

Which is exactly the reasoning I posted above - the problem is that you are not consistent with using this reasoning in deciding who should qualify for "free" health-care.

[Ivor the Engineer]

Which is exactly the reasoning I posted above - the problem is that you are not consistent with using this reasoning in deciding who should qualify for "free" health-care.

Please point out my inconsistencies and I will correct them.

[Darat]

That assumes that what they end up dying of costs the same or less than treating CVD.


Er no it doesn't, if statins don't increase lifespan whether they have them or not they will live the same amount of time and therefore will require the same treatments. Only if statins significantly increase lifespan would there be additional costs incurred by the NHS.



Making people pay for their quick-fix drugs encourages them to live in a way that we know will result in a general better state of health.

Any evidence to support this?

[Darat]

Please point out my inconsistencies and I will correct them.

Ivor - I have already done so several time (and others have as well) for some reason you don't seem to see your inconsistent application of your reasoning over this issue.

I'll try again - there are whole range of factors that mean some people are more likely to develop CVD, many of these factors are "choices" people make however you only seem to use the fact that people make these choices in certain areas.

This means that you would provide all the treatment someone overweight requires after they have had a stroke but you won't provide treatment for them before they have a stroke because they are overweight and that is their "choice".

Yet you won't apply the same reason to people in a "lower" social-economic grouping despite the fact we know that increases their individual risk of developing CVD (regardless of other risk factors such as being overweight).

This is just not consistent. Now don't get me wrong I don't expect perfect consistency from first principles when we are discussing real-world situations but (so far) the reason you have produced for not giving treatment to people that you have decided have a "bad" lifestyle seems to be based on nothing more than to be blunt "fat people can choose not to be fat and if they choose to be fat - tough".

[Ivor the Engineer]

Er no it doesn't, if statins don't increase lifespan whether they have them or not they will live the same amount of time and therefore will require the same treatments. Only if statins significantly increase lifespan would there be additional costs incurred by the NHS.

That is incorrect. For example, if person not on statins has a non-fatal heart attack at 50, lives 10 more years, during which time they are less mobile so avoid the need for a hip replacement. A person on statins puts the heart attack off until 60, is more mobile and needs a hip replacement at 55.

Any evidence to support this?

That if you offer treatment for what is the better long-term solution (weight loss, diet changes, stop smoking) for less than the short-term quick-fix (statins), that you will get more people taking up the better long-term solution?

I'll try to find some for you, but positive and negative financial incentives are used all over the place to influence our behaviour.

[Darat]

That is incorrect. For example, if person not on statins has a non-fatal heart attack at 50, lives 10 more years, during which time they are less mobile so avoid the need for a hip replacement. A person on statins puts the heart attack off until 60, is more mobile and needs a hip replacement at 55.


Lifetime costs are the same for both scenarios (adjusted for inflation).




That if you offer treatment for what is the better long-term solution (weight loss, diet changes, stop smoking) for less than the short-term quick-fix (statins), that you will get more people taking up the better long-term solution?

I'll try to find some for you, but positive and negative financial incentives are used all over the place to influence our behaviour.

I don't disagree they are used but you need to show that your balance would be effective in this scenario.

[Ivor the Engineer]

Ivor - I have already done so several time (and others have as well) for some reason you don't seem to see your inconsistent application of your reasoning over this issue.

I'll try again - there are whole range of factors that mean some people are more likely to develop CVD, many of these factors are "choices" people make however you only seem to use the fact that people make these choices in certain areas.

This means that you would provide all the treatment someone overweight requires after they have had a stroke but you won't provide treatment for them before they have a stroke because they are overweight and that is their "choice".

Yet you won't apply the same reason to people in a "lower" social-economic grouping despite the fact we know that increases their individual risk of developing CVD (regardless of other risk factors such as being overweight).

This is just not consistent. Now don't get me wrong I don't expect perfect consistency from first principles when we are discussing real-world situations but (so far) the reason you have produced for not giving treatment to people that you have decided have a "bad" lifestyle seems to be based on nothing more than to be blunt "fat people can choose not to be fat and if they choose to be fat - tough".

Overweight and obese people should be treated for their weight problem, not given medication to mitigate the risks of staying overweight or obese. The same goes for all unhealthy behaviours within the control of the individual.

Does being in a lower socio-economic group increase their individual risk of developing CVD, or do individuals who behave in a way that increases their individual risk of developing CVD often come from a lower socio-economic group?

I'll concede that if the former is true, that would be a valid reason to provide risk-reducing medication to people from that socio-economic group.

[Darat]

Overweight and obese people should be treated for their weight problem, not given medication to mitigate the risks of staying overweight or obese. The same goes for all unhealthy behaviours within the control of the individual.


So what happens when, as I said at the beginning of this, a fat person just misses the "target" weight that you've decided is "good" and their cholesteral level and ratio is still not ideal - in your system they are stuffed (pun intended)!


Does being in a lower socio-economic group increase their individual risk of developing CVD, or do individuals who behave in a way that increases their individual risk of developing CVD often come from a lower socio-economic group?

I'll concede that if the former is true, that would be a valid reason to provide risk-reducing medication to people from that socio-economic group.

I've just had a look if I kept the link and I didn't - but in a debate awhile ago someone did bring up a study that showed that for many classes of diseases (including CVD) social-economic grouping is a "risk factor" regardless of other criteria such as weight, smoking and so on.

But you are again being inconsistent- if I am in a "lower" social economic group I can change my life to change that just like I can change my life if I am fat so why is it only if I'm fat you would not allow me free statins?

[Ivor the Engineer]

So what happens when, as I said at the beginning of this, a fat person just misses the "target" weight that you've decided is "good" and their cholesteral level and ratio is still not ideal - in your system they are stuffed (pun intended)!

How is my system different in this respect to the one we have now? You still have to meet arbitrary criteria before you are prescribed statins. What if you only have a 19% risk, rather than a 20% risk in the next 10 years of a CVD event under the current system?

Just for clarification, decisions would not be based on hard targets, they would be based on reality E.g., if a slightly overweight person came in with a cholesterol level of 13mmol/l, they have a cholesterol problem which would be unlikely to be much affected by their lifestyle and would get statins. If a obese person came in with a cholesterol level of 7mmol/l, they would be treated for their obesity, rather than be given statins.

I've just had a look if I kept the link and I didn't - but in a debate awhile ago someone did bring up a study that showed that for many classes of diseases (including CVD) social-economic grouping is a "risk factor" regardless of other criteria such as weight, smoking and so on.

But you are again being inconsistent- if I am in a "lower" social economic group I can change my life to change that just like I can change my life if I am fat so why is it only if I'm fat you would not allow me free statins?

A health system can only be expected to deal with physical and mental problems associated with an individual's health. Or should doctors be advising their patients to live in Japan?

[casebro]

So far as cholesterol as a risk factor for heart disease, I believe it is #5. Ahead of it are: Age, Weight, Family history, and Height. It would make more sense to cut two inches out of your femurs than to take statins. ;)

OK, so it's the #1 CONTROLLABLE risk factor. Being #5 makes it barely worth while. Which is born out by the studies.

[Ivor the Engineer]

So far as cholesterol as a risk factor for heart disease, I believe it is #5. Ahead of it are: Age, Weight, Family history, and Height. It would make more sense to cut two inches out of your femurs than to take statins. ;)

OK, so it's the #1 CONTROLLABLE risk factor. Being #5 makes it barely worth while. Which is born out by the studies.

It's a bit old (1998), but this (http://www.york.ac.uk/inst/crd/ehc41.pdf) has some interesting information on chlesterol and heart disease.

Of particular interest are figs. 4 and 5. Should we all be aiming for a total cholesterol of less than 3.5mmol/l? What are the side effects (if any) of a serum cholesterol level this low?