Millions more people should be put on cholesterol-lowering statin drugs to protect them against heart attacks and strokes, according to draft guidelines for the NHS in England.
The National Institute for Health and Care Excellence (NICE) says the scope for offering this treatment should be widened to save more lives. Death rates have been decreasing in recent years, but cardiovascular disease remains the leading UK killer. It claims about 180,000 lives a year.
Currently, doctors are meant to offer statin tablets to the estimated seven million people who have a 20 per cent chance of developing cardiovascular disease over 10 years, based on risk factors.
Doctors use a risk calculator called QRisk2 to work out a person’s chance of having a stroke or heart attack to decide if they should be given statins. The calculation factors in things such as age, weight and smoking.
If someone has a 10-year QRisk2 score of 20 per cent, then in a group of 100 people like them, on average, 20 would get cardiovascular disease over the next 10 years. Or put another way, they have a one-in-five chance of developing cardiovascular disease over the next decade. NICE is now suggesting that people with as low as a one in 10, or a 10 per cent risk, should be offered statins.
Doctors will need to make a judgement about the risks to people who have a less than 10 per cent risk of developing cardiovascular disease, and advise them appropriately, say the guidelines.
The current spend on statins by the NHS is about £450m a year. If the draft recommendations go ahead, this bill will increase substantially, although the drugs have become significantly cheaper over the years.
It is not clear precisely how many more people would be eligible for statin therapy than now, but NICE says it could be many hundreds of thousands or millions. Peter Weissberg, of the British Heart Foundation, said the guidelines did need updating and agreed that more people stood to benefit from taking statins. However, former GP Kailash Chand says: “Statins should be used judiciously, where they are needed, not for healthy people.”
Advice on lifestyle such as eating a healthy diet, doing regular exercise and keeping slim will also help lower cholesterol and would probably be of more benefit than statins as like all medicines, they have potential side effects. They have been linked to muscle, liver and kidney problems, but only in a very small number of cases.
Simon Maxwell, of the British Pharmacological Society, said: “Patients should be helped to make a truly informed decision about the benefits and risks of taking long-term preventative therapy that will not make them feel any better in the short term. We should avoid misapplication of such a recommendation without proper individual patient counselling.”
Similarly, many of us take an aspirin a day just in case. New evidence suggests that the risks outweigh any benefits, and people need to think twice. This ultimate, just-in-case lifestyle pill offers protection against heart disease and bowel cancer and doctors regularly recommend it as part of the general health regimes to all their patients who are 50 and over.
Patients should be helped to make a truly informed decision about the benefits and risks of preventative therapy
However, a major new analysis of the risks and benefits of routine aspirin use paints a worrying picture; it could be costing as many lives as it saves.
“There is an incredibly fine balance between the possible benefits and risks of the intervention,” points out Aileen Clarke, who led the team of investigators at Warwick Medical School in Coventry, UK (Health Technol. Asses., 2013).
The benefits of taking aspirins are certainly real, but possibly far less impressive than doctors would have us believe. Taking an aspirin every day for 10 years can reduce the rate of major cardiovascular events such as heart attacks by around 10 per cent and coronary disease by 15 per cent, the Warwick researchers have discovered.
The same picture emerged for lives saved from colon cancer; after taking aspirin every day for five years, there were 34 fewer deaths per 100,000 people.
Any life saved has to be worth it, they state, but compare that to the estimated 130,000 lives that might be saved every year from all cancers if every adult in the US (for example) took a multivitamin supplement every day (Nutrients, 2013).
The problems became apparent when the Warwick researchers discovered aspirin increases the rate of gastrointestinal (GI) bleeding by 37 per cent and the risk of stroke by 38 per cent. Translated into figures, this means there are 117 extra cases of GI bleeding per 100,000 people taking aspirin and up to 10 additional cases of stroke, which is debilitating at best and fatal at worst.
To clarify the full extent of just-in-time aspirin use, people around the world swallow approximately 100 billion aspirin tablets each year, and that is increasing by 15 per cent per year.
A study of 22,000 doctors could find no protective effects and neither did one involving nearly 40,000 women given either 100mg of aspirin or a placebo pill for 10 years. At the end of the study, the numbers of cases of cancer in both groups were similar (Jama, 2005).
The key is finding the balance between risk and benefit from the just-in-case medication. Are there other alternatives?
kathryn@maltanet.net