Mainstream media coverage of various healthcare subjects is often prone to sensationalism, designed to invoke attention and engagement, making it difficult for the general public to discern what is true and what is not. Statins, in particular, have been controversial for many years, despite their widespread usage, and many articles have cast their usefulness into doubt.
Social media is also playing an increasingly significant role in healthcare and in patient attitudes towards certain medications, including statins. Although we know that social media can serve as an excellent tool for patient education, it can also help to spread inaccurate or sensationalised information. Research is useful in ascertaining what people outside healthcare think and feel about a medication and provides some insight into what patients may be thinking, but not disclosing. Such insight may aid health professionals in opening up discussions with patients about information obtained through their own independent research, so that the professional can answer any questions, clarify misconceptions and empower and support the patient to make informed choices.
Statins and the patient experience
In a recent study published in the British Medical Journal, Cai et al (2021) aimed to assess the associations between statins and adverse events in the primary prevention of cardiovascular disease, analysing how the adverse events can vary according to the type and/or dosage of statin given.
The systematic review and meta-analysis assessed previous systematic reviews listed on Medline and other reputable databases up to August 2020. Studies included randomised controlled trials in adults with no history of cardiovascular disease, whereby statins were compared with non-statin controls, or different types or dosages of statins were compared. The primary outcomes were the common adverse events, including self-reported muscle symptoms, clinically confirmed muscle disorders, liver dysfunction, renal insufficiency, diabetes, and eye conditions. Secondary outcomes were defined as myocardial infarction, stroke, and death from cardiovascular disease as measures of efficacy.
Cai et al (2021) analysed and compared the results of 120 456 participants across 62 trials, with an average follow-up of 3.9 years. Statins were found to be associated with an increased risk of self-reported muscle symptoms in 21 trials; liver dysfunction in 21 trials; renal insufficiency in 8 trials; and eye conditions in 6 trials. However, they were not found to be associated with any confirmed clinical conditions, such as muscle disorders or diabetes. Although patients' experiences should not be discounted, there was a clear distinction between what a person thought they were experiencing, based on their symptoms, and the reality of their actual disorder. Therefore, the increased risk of the development of the aforementioned side effects and symptoms were not found to outweigh the reduction in major cardiovascular events.
Atorvastatin, iovastatin and rosuvastatin were found to be individually associated with some adverse events, but few significant differences were found between the types of statins administered. An Emax dose-response relationship was observed for the effect of atorvastatin on liver dysfunction, but the researchers found that other dose-response relationships for the other statins and adverse effects were inconclusive (Cai et al, 2021).
Overall, Cai et al (2021) concluded that, for the prevention of cardiovascular disease, the risk of adverse events attributable to statins was low and did not outweigh their efficacy in the prevention of cardiovascular disease, which suggests that the benefit-to-harm balance of statins is generally favourable. However, the use of statins carries an increased risk of liver dysfunction; therefore, routine monitoring of liver function throughout treatment is recommended by companies that produce statins. The researchers also noted that there was limited evidence to validate the tailoring of the type or dosage of statins to account for safety concerns before commencing treatment, which is an area that could be further explored (Cai et al, 2021).
While statin efficacy generally outweighs risk, there is a clear need for further research to help improve adherence to these medications, so that patient characteristics can be identified that are significant in the occurrence of adverse events, as this may be based on individual-level data in clinical practice (Cai et al, 2021). Such research may also analyse associations between statins and more severe long-term adverse events using observational research and pharmacovigilance data from a large cohort, which may help researchers detect the rarer adverse events that can occur on a minor scale.
Policy and treatment
The National Institute for Health and Care Excellence (NICE) (2021) recommended wider use of statins for the prevention of cardiovascular disease, suggesting that GPs offer atorvastatin 20 mg for primary prevention to people identified as having a 10% or greater risk of developing cardiovascular disease within the next decade, or to patients with type 1 or 2 diabetes. However, those with established cardiovascular disease may require 8027mg atorvastatin (NICE, 2021).
NICE (2021) also recommends that doctors discuss the benefits of lifestyle modifications with their patients before starting statin therapy, and that the QRISK2 assessment tool should be used to establish cardiovascular risk in all patients. GPs are facing increasing demand, but NICE states that this additional guidance should not increase their workload. The new guidance is based on an additional 4.5 million people who could need statins, potentially preventing up to 28 000 myocardial infarctions and 16 000 strokes annually (NICE, 2021).