Sorry to be absent, I’ve about a zillion big things shortly coming to fruition, at which point expect a deluge.
Everyone is having kittens about statins and the BMJ at the moment. Here’s what I wrote as a rabid response on the latest BMJ editorial about it, and a disco soundtrack to keep your attention focused:
Statins are a mess: we need better data, and shared decision making
I have two observations to make on the statin wars.
Firstly: if there is any uncertainty at all about the risks and benefits of statins – and there is – then we have failed to competently implement the most basic principles of evidence based medicine. Statins are the single most commonly prescribed class of treatment in the developed world, taken by tens if not hundreds of millions of patients every day. That would be more than enough clinical experience to resolve any research questions, if we were competently identifying all outstanding uncertainties, and conducting well-designed trials to answer those questions in routine clinical care . We need better data; better dissemination of that data; and better communication of that data, in ways that help people make decisions which reflect their wishes. Statins should be the crowning glory of evidence based medicine, our perfection incarnate: instead, they are a mess.
Secondly: while disputes over individual numbers are important, the leading protagonists in the statin wars seem, above all, to be suffering under a grand delusion that all patients think like they do. On the one hand, we have clinicians and researchers insisting that no sane patient would refuse a safe simple treatment that reduces their chances of a heart attack by one in 200; on the other, we have clinicians and researchers insisting that one in 200 is a laughable and trivial benefit, which no sensible patient could ever care about.
In reality, all patients are different, and we all – as doctors or as patients – weigh up different factors differently. Some want longevity at any cost; some think taking a pill every day is an affront to their independence. Some think aching muscles are a trivial niggle; some think that side effects – even when mild, well-documented, and carefully discussed – are proof that their doctor is a reckless idiot.
When we offer statins, or any preventive treatment, we are practicing a new kind of medicine, very different to the doctor treating a head injury in A&E. We are less like doctors, and more like a life insurance sales team: offering occasional benefits, many years from now, in exchange for small ongoing costs. Patients differ in what they want to pay now, in side effects or inconvenience, and how much they care about abstract future benefits. Crucially, the benefits and disadvantages are so closely balanced that these individual differences in preference really matter.
Because of that, this new kind of medicine needs perfect information. We need clean, clear data showing the risks and benefits of preventive treatments, on real world outcomes, beyond any reasonable doubt, at every level of risk, and for as many subgroups as possible. We need shared decision making products that are universally available, carefully validated, and seamlessly integrated into routine clinical care, to help all patients make their own truly informed decisions. Lastly, we need to recognise that different patients have different priorities: different to each other and, sometimes, very different to our own.
Research Fellow in Epidemiology
London School of Hygiene and Tropical Medicine
 Staa T-P, Goldacre B, Gulliford M, et al. Pragmatic randomised trials using routine electronic health records: putting them to the test. BMJ. 2012;344(feb07 1):e55-e55. doi:10.1136/bmj.e55.
I might expand this with a colleague for a longer piece.
Also, I’m thinking of rattling out a very quick 90 page book on statins: they are the single most commonly prescribed treatment in the entirety of the developed world. If we fail on statins, then documenting those shortcomings is the roadmap to perfection, and getting 100 million patients involved in that discussion is one way to jolt two of my professions (academia and medicine) out of our complacency.
Lastly, we have an interesting new trial in the pipeline in this area, on which more shortly.