Statins: The Good, the Bad, and the Unknown

Clinicians Are Talking About Statins

Gordon H. Sun, MD, MS


October 10, 2014

In This Article

Personal Beliefs Regarding Statins

One physician astutely observed that "what is most remarkable here [at Medscape] is that so few physicians have commented favorably on the use of statins." The reader then postulated that the overwhelming number of comments against broad use of statins as primary prevention of CVD perhaps reflected a biased sample.

This is certainly a reasonable possibility. The international From the Heart study[30] interviewed 750 physicians from Europe, Asia, and Central America, examining opinions about the relative importance of causes and treatments for high cholesterol in 2007 (before the ACC/AHA guideline). This survey found that 56% of physicians prescribed statins with or without lifestyle changes as first-line therapy for dyslipidemia, compared with 43% who prescribed lifestyle changes alone. Most physicians also reported that they believed that lifestyle changes were ineffective alone, difficult to maintain over a long period of time, and patients would become discouraged if they saw no improvements with diet and exercise regimens. This philosophy was reflected in another Medscape reader comment that "many docs use statins as first choice as many patients are noncompliant when it comes to diet, etc."

However, several other studies have suggested that both providers and patients may be more in favor of lifestyle modification over statins in prevention of CVD. Vamvakopoulos and colleagues[31] published a three-part survey conducted during February-May 2005 of 99 general practitioners, 79 pharmacists, and 121 potential consumers in the United Kingdom on issues related to the over-the-counter availability of simvastatin (Zocor®) 10 mg. All three groups of participants reported that improving lifestyle habits such as smoking cessation, proper diet, and regular exercise were more effective than statins in preventing CVD (pharmacists 54.4%, physicians 72.6%, and consumers 95.0%).

A 2010 survey[32] of 98 Kaiser Permanente Southern California members examined reasons for nonadherence to prescribed statin therapy. Among 73 people who did not fill the prescription at any pharmacy, the most commonly cited reasons included general concerns about taking the medication (63.0%), a decision to attempt lifestyle modifications (63.0%), and fear of side effects (53.4%).

JAMA has been no stranger to the statin debate. In fact, the "Dueling Viewpoints" section of JAMA, intended to encourage a vigorous discussion of controversial medical topics, used the question of whether a healthy middle-aged man with elevated cholesterol should begin statin therapy as its inaugural topic.[33,34,35] Since the publication of the ACC/AHA guideline, the New England Journal of Medicine (NEJM)[36] weighed in on the statin controversy with an interactive clinical vignette of a 52-year-old white man with an estimated 10-year ASCVD risk of 10.9%. The journal subsequently published the results from the responses of 1641 readers from 97 countries who weighed in on the issue.[37] Most NEJM respondents (57%) favored no initiation of statin therapy; 50% of respondents in the United States and Puerto Rico chose not to start statin therapy compared with 60% of respondents in other countries. The poll results showed that most respondents were strongly in favor of lifestyle modifications, particularly smoking cessation (the patient in the case vignette was a smoker). Many respondents expressed concerns about statin-related side effects, whereas others discussed the importance of shared decision making. The minority of NEJM respondents who recommended starting statin treatment believed that lifestyle modifications were desirable in theory but difficult to achieve in practice.

These themes were echoed in comments made by Medscape readers. Lifestyle modifications were commonly suggested as first-line therapies, although several readers also mentioned use of niacin and omega-3 fatty acid supplements. The ACC/AHA guidelines discuss safety precautions and contraindications associated with the use of these compounds, but the guidelines otherwise provide little direction in terms of populations who potentially might benefit from these therapies. Of note, the United Kingdom's National Institute for Health and Care Excellence (NICE) clinical guideline 181,[38] released in July 2014, states that niacin or omega-3 supplements should not be offered to patients being treated for primary prevention of CVD. Clinicians also warned against becoming "[statin] prescription pad scientists," urged avoidance of "cookie cutter medicine," and expressed concerns about colleagues treating "numbers" and not people. Ultimately, regardless of whether the Medscape and NEJM respondents supported or opposed statins as primary preventive therapy, all believed that a detailed discussion with the patient was the most appropriate decision.


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