Health: Lessons in healthy skepticism and high value care
MOHLER’S MEDICATION MAXIMS
In November 2013, the American College of Cardiology and the American Heart Association released new guidelines for the use of “statin” drugs. These new guidelines are revolutionary in their scope:
1. You and your clinician no longer need to know and chase your LDL (bad cholesterol) number. The notion that statins work to prevent heart disease by simply lowering the cholesterol level has been debunked.
2. Drugs like ezetimibe (Vytorin, Zetia) and niacin do lower LDLs and have a very minimal role in care, as they do not decrease heart attacks or strokes in most people.
3. The new guidelines emphasize the strong evidence that shows that statins may be life saving for patients who have had previous heart attacks or strokes, most diabetics and for patient who have very high LDLs.
These three recommendations are based on solid science: large clinical trials and a preponderance of evidence over decades. The guideline committee should have quit there, but they went on to suggest that we should use the online risk calculator (http://my.americanheart.org/cvriskcalculator) they thoughtfully provided. It predicts our risk for a heart attack or stroke in the next ten years. Three days later, two professors from Harvard Medical School published data that demonstrated that the new risk calculator overestimated the risk of heart attack and stroke by 75 to 150 percent. Uproar!
This guideline tool could result in more than 45 million Americans, who do not have cardiovascular disease, being recommended for statin therapy. Playing with the risk calculator is instructive. For a healthy Caucasian non-smoking patient with no diabetes and healthy levels of blood pressure and total and good (HDL) cholesterol, age alone will prompt statin therapy — beginning at age 63 for men and at 70 years for women. The calculator is the ultimate machine for turning “people into patients — making the well, ill.”
Be skeptical! Seven of the 15 members of this guideline committee had significant conflict of interests with the pharmaceutical industry. Is this important? I believe that it is.
High Value Care or Not? You Decide.
For those at low risk of a heart attack or stroke, 140 persons must take a statin for five years to prevent one heart attack or stroke. So 139 of those 140 low risk patients, who take a statin for five years, will receive absolutely no benefit, but are subject to the costs and side effects of the statin. Recall that one of every five statin patients will experience some ill effect from the drug.
On the other hand, if you have had a stroke, a TIA, a heart attack, have diabetes or a very high LDL, the health care value of taking a statin may be very different. For patients with known heart disease, 39 patients have to take a statin for five years to prevent one non- fatal heart attack.
Finally, if you decide you are a candidate for statin therapy, be wise about the statin choices. For the most part, a statin is a statin is a statin. There is some variation in potency. Almost all statins are now available as generic drugs. They are cheap — less than $10 per month. Crestor, available only as the brand name product, is the glaring pricey exception. Checking GoodRx on Aug. 29 the best prices in town for a month’s worth of Crestor 20mg are $153 at Sam’s Club and $229 at Kmart.
It has been estimated that if we could move all those patients who are taking Crestor to a generic statin, our national health care system could save $5 Billion per year. More importantly, what could you do with an extra $143 a month? Talk to your physician.
Free Press health columnist Dr. Mohler has practiced family medicine in Grand Junction for 39 years. He has a particular interest in pharmaceutical education. Phil works part-time for Rocky Mountain Health Plans. Email him at email@example.com.
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