Who Benefits From Taking a Statin, and When?

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Northerner

Northerner

Admin (Retired)
Relationship to Diabetes
Type 1
Some time ago, a 38-year-old woman consulted me to discuss how she could reduce her chances of myocardial infarction or stroke. Her low-density lipoprotein cholesterol level was ≈160 mg/dL and she had recently quit smoking after her sister had a heart attack. She was not so much interested in her absolute risk of atherosclerotic cardiovascular disease (ASCVD), but she wanted to know "if" she could benefit from taking a statin and "when" to start doing so. I was unable to provide her with unequivocal answers. This made me think about how we approach primary prevention of ASCVD.


The Current Paradigm
Atherosclerosis does not affect all of us, and does not affect all those struck by it to the same extent or at similar age. In part these differences remain elusive, but the most important determinants have been known for nearly 60 years: the first concept of "factors of risk" in medicine dates back to one of the early publications from the Framingham Heart Study describing the associations of serum cholesterol concentrations and systolic blood pressure with the incidence of coronary heart disease.[1] Currently, we have a clear understanding how cumulative exposure to atherogenic lipid fractions drives the process of atherosclerosis across the lifespan through a complex interplay of genetic and lifestyle determinants.[2–4]

Statins are generally well-tolerated and safe drugs to lower low-density lipoprotein cholesterol levels and consequently lower ASCVD risk.[5] Statins rank among the most studied drug classes: half of the middle-aged population without ASCVD would have been eligible for at least one of the many randomized trials demonstrating the effectiveness of statins in a primary prevention setting.[6] These trials each targeted a subgroup of the general population with specific atherogenic attributes, including dyslipidemia, diabetes mellitus, hypertension, and chronic inflammation. The evidence provided by these trials is implemented in clinical practice guidelines around the globe: statins are recommended for primary prevention in patients with extremely high low-density lipoprotein levels, patients with diabetes mellitus, and patients with the greatest short-term (ie, 10-year) predicted risk of ASCVD, because these groups are deemed to derive the greatest short-term benefit from treatment.

www.medscape.com

Who Benefits From Taking a Statin, and When?

Should we be starting patients on statins at a younger age? This essay examines the expected benefits of and uncertainties surrounding long-term statin use in younger individuals.
www.medscape.com
 
The only criterion for starting in statins is high LDL levels, regardless of other conditions. Nobody has demonstrated unequivocally that statins help those without high LDL levels because you can't do controlled trials. There is, therefore, no evidence they do any good,whatever doctors "deem".
 
A few years ago, I was told everyone over 40 with diabetes was given statins regardless of cholesterol levels. This is due to the higher risk of heart disease diabetes brings.
However, this research was not with people following an otherwise "healthy" lifestyle such as frequent exercise, not obese, etc. At the time I was told, there had been no research on the benefits of statins for people who exercise frequently.
 
This is a conversation that keeps coming up with my consultant now... I’m still not sure what I should do. My cholesterol is 4.2 so slightly high but I exercise regularly and I’m not obese.
reviewing again in 6 months but I read pros and cons and I’m still no wiser.
 
Type 1s needn't worry. We are just normal people who take external insulin to compensate for the missing insulin. Most of the "diabetes" data is on Type 2s, which is an extremely multifactorial condition. It's type 2s who need worry about their likelihood of developing heart disease in later life, the risk is there.

That said, we may be just normal people, but normal people can develop hyperlipidaemia, so go by blood tests, not by edict. This, of course assumes the diabetes is well controlled.
 
grainger said:
This is a conversation that keeps coming up with my consultant now... I’m still not sure what I should do. My cholesterol is 4.2 so slightly high but I exercise regularly and I’m not obese.
reviewing again in 6 months but I read pros and cons and I’m still no wiser.
Click to expand...
Sounds just like me! 🙂 I stopped taking them (and largely stopped listening) nearly 12 years ago 🙂 They are powerful drugs, so I want a watertight reason for taking them - I've never been given one.
 
Neither my oncologist (who tests my bloods quarterly) or the hospital diabetes team have raised Statins with me. The last 3 GP's i have talked to at the surgery have all mentioned prescribing them but agreed to leave it with the oncologist. T1, aged 57, and borderline obese......
 
A few weeks of Atorvastatin and Metformin badly damaged my brain's ability to function on a Human level. I was forgetful, unable to cook a meal without some things being almost raw and others burnt, and even now over three years later I still find things I have lost the memory of. I had to relearn all my songs - luckily I had begun to write them down for my daughter so had about 300 to work on.
I can't see how there ought to be a universal use of statins if even a small proportion of people could end up requiring assisted living for the rest of their lives, which would be spent in a dazed state.
 
I've just looked up the NICE guidance on this and it says

Primary prevention for people with type 1 diabetes
1.3.23 Consider statin treatment for the primary prevention of CVD in all adults with type 1 diabetes. [new 2014]
1.3.24Offer statin treatment for the primary prevention of CVD to adults with type 1 diabetes who:
  • are older than 40 years or
  • have had diabetes for more than 10 years or
  • have established nephropathy or
  • have other CVD risk factors. [new 2014]
1.3.25 Start treatment for adults with type 1 diabetes with atorvastatin 20 mg. [new 2014]

Primary prevention for people with type 2 diabetes
1.3.26 Offer atorvastatin 20 mg for the primary prevention of CVD to people with type 2 diabetes who have a 10% or greater 10‑year risk of developing CVD. Estimate the level of risk using the QRISK2 assessment tool. [new 2014]
 
I wonder why they choose atorvastatin rather than simvastatin. I think they're rather similar except from a significant difference in price (with atorvastatin being over 10 times more expensive)?

(Indeed, I seem to remember Ben Goldacre bemoaning the difficulties of setting up a trial to compare the two by randomising GP surgeries or GPs or patients. Technically easy to do on a big scale, but would need lots of work to satisfy informed consent and similar. Maybe there are deals making the price difference not so significant now?)
 
helli said:
I've just looked up the NICE guidance on this and it says

Primary prevention for people with type 1 diabetes
1.3.23 Consider statin treatment for the primary prevention of CVD in all adults with type 1 diabetes. [new 2014]
1.3.24Offer statin treatment for the primary prevention of CVD to adults with type 1 diabetes who:
  • are older than 40 years or
  • have had diabetes for more than 10 years or
  • have established nephropathy or
  • have other CVD risk factors. [new 2014]
1.3.25 Start treatment for adults with type 1 diabetes with atorvastatin 20 mg. [new 2014]

Primary prevention for people with type 2 diabetes
1.3.26 Offer atorvastatin 20 mg for the primary prevention of CVD to people with type 2 diabetes who have a 10% or greater 10‑year risk of developing CVD. Estimate the level of risk using the QRISK2 assessment tool. [new 2014]
Click to expand...

Sort of on a tangent, but I wonder why the recs from the Jan 2018 Surveillance Report don't seem to have been addressed in the guidelines?

Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance | NICE

www.nice.org.uk www.nice.org.uk

Eg:

- Update rec to QRISK3 rather than QRISK2 for risk assessment, and maybe now use it for T1's also.
- Maybe include Rosuvastatin as a recommended statin, based on the trial results and the fact that it's now off patent.
- Updated evidence that the lower the LDL-C level, the better.
- Better handling of statin intolerance
- Maybe update recs to include PCSK9 inhibitors like Alirocumab
 
Drummer said:
I can't see how there ought to be a universal use of statins if even a small proportion of people could end up requiring assisted living for the rest of their lives, which would be spent in a dazed state.
Click to expand...
Agree, even a tiny percentage can equate to a lot of people, and with no assured benefits at the outset for the majority. I remember seeing a little graphic when I was debating them - it showed that, of 100 people not on statins then 93 might avoid a cardiovascular 'event'. If you put all 100 on a statin then 96 will avoid an event. So for 93 people/100 it makes no difference, but some of them might suffer serious side-effects that they would have avoided.
 
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