Blog | Thursday, January 16, 2014

A clear example of how values matter in judging statins for primary prevention


JAMA has an article and an editorial that favor using statins for primary prevention. The clinical evidence and the editorial focus on the relative risk improvement with statins. However, the clinical evidence reports on a number needed to treat for 5 years of 138 to prevent 1 death. So 5 years of statin therapy for 138 patients to prevent 1 death. Is this a reasonable trade off?

The lipidologists obviously see this as a victory for their hypothesis. They quote data that patients tolerate statin therapy as well as they tolerate placebo. They now have the evidence. We should give many more patients statins!

Many critics will view these data differently. 690 years of statins to prevent 1 death seems like a weak result (I multiplied 138 by 5 to get the number of statin years). How do we value a year of statins? Since the studies mostly used pravastatin, the cost to the patient should be around $50 per year. What about side effects? Primary care physicians have a different view of statin side effects than do lipid specialists. Patients have a different viewpoint.

Is there a correct answer? Is our own goal decreasing deaths? Some would argue it is the primary goal. Others would argue that every additional drug has its own hazards. They would dispute the side effect data in the randomized controlled trials.

And this is why we have controversies in medicine. Our decisions do depend on how we define problems. The definition of our prevention goals remain fuzzy to many physicians.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.