Would You Like Statins With That?

Photo by corpse reviver

As we wrote on this blog the other day about research which raised questions about the efficacy of statins for those who have not yet experienced a heart attack– an off label prescription–the WSJ pointed to a new paper in the American Journal of Cardiology from authors at  Imperial College, London, U.K., which suggests that  statins should be made available free of charge to consumers along with the purchase of fast food. The press release from Imperial College can be found here.

Low level doses of statins may be purchased over the counter in England.

In a prior post, I  wrote about meeting with a cardiologist who suggested I commence taking statins because of my various cardio risk factors. A point, however uncomfortable at the time, made ultimately moot by the favorable results of my stress test, echocardiogram and calcium scoring. I had, prior to my surprisingly clean bill of cardiac health, relented mentally to the prospect of what would become a life long prescription. Of statins, I wrote:

“If one has risk factors, it is prophylactic and is prescribed to reduce the risk of heart attack, stroke and other heart diseases. It is doubtful whether once I start taking this drug I will ever stop. There is no foreseeable time (while alive) that I will wish to stop reducing the risk of heart attack or stroke. And that I suppose is the essence of the onset of age– piling up prescriptions. A daily regimen that will follow one to the grave–only the dosages or the brand names changing as each day welcomes a regimen of pills. In short, this prescription feels like the onset of dependence. The forward guard, if you will. A harbinger of a pharmaceutical future.”

One might say I didn’t take the news well. But crucial to my decision to relent were the words of my cardiologist and another heart doctor. I wrote:

Seeing my, shall we say, chagrin, the cardiologist told me that, like over 50% of the cardiologists he knows, he takes a statin. “We’ve seen the data.” Another recently told me  “Yeah, I take it. They should put it in the water.”

And now, apparently, in burgers.

But, we wrote of some  important (and conflicting) recent findings regarding statins here at HRW last week:

A LA Times article has recently highlighted the problems of off label prescriptions.  In the article, it has come to light that the off label use of statins, one of the world’s most prescribed medication, may not have the efficacy that many doctors had previously thought.  The LA Times reports,

Statins were initially approved by the Food and Drug Administration for the prevention of repeat heart attacks and strokes in patients with high cholesterol who had already had a heart attack. And used for that purpose - called “secondary prevention” - the drugs are powerful and effective medications, driving down patients’ risk of another heart attack or stroke by lowering their levels of LDL (or “bad”) cholesterol.

Then physicians came to believe statins could also reduce the risk of a first heart attack in people who have high LDL cholesterol but are nonetheless healthy. This use of statins - called “primary prevention” - has driven the growth in the market for statins over the last decade.

Statins certainly decrease rates of heart attack in people who have clear signs of cardiovascular disease but it’s not so clear they work that way in people who are healthy. In spite of that uncertainty, statins’ use for primary prevention has sky rocketed.

One wonders how so many physicians came to believe that statins could also reduce the risk first time heart attacks.  Dr. John Abramson, from Harvard Medical School, attributes statins’ off label growth to a “conspiracy of false hope.”  He states, “[t]he public wants an easy way to prevent heart disease, doctors want to reduce their patients’ risk of heart disease and drug companies want to maximize the number of people taking their pills to boost their sales and profits.”

So, with all these interests pushing for statins’ off label use, it should not be a great surprise that extensive research has not been performed regarding statins’ primary preventive effects- and conflicting results have emerged.  The LA Times reports,

In the first of three studies published in the Archives last month, medical researchers found that, contrary to widely held belief, statins do not drive down death rates among those who take them to prevent a first heart attack. A second article cast significant doubt on the influential findings of a 2006 study, called JUPITER, that has driven the expansion of statins’ use by healthy people with elevated blood levels of C-reactive protein, a measure of inflammation. A third article suggested potential ethical, clinical and financial conflicts of interest at work in the execution of the JUPITER study and concluded the widely hailed trial was “flawed” and raises “troubling questions concerning the role of commercial sponsors.”

So??? Statins anyone?

Not So Fast With That Lipitor Johnny!

Score of Baude Cordier's chanson "Belle, bonne, sage," from The Chantilly Manuscript, Musée Condé 564. The manuscript is one of the classic examples of ars subtilior, which requires red notes, or "coloration" to indicate changes in note lengths from their normally written values. This chanson, a dedicatory piece on the love of a lady and a lord written in the shape of a heart, opens the corpus. Note the heart of notes within the larger heart. Date, ca. 1350-1400

Having previously described my diet, proclivities, and the thoroughly reasonable fear I had regarding the battery of tests I would have to undergo this week at the Cardiologist’s, I am pleased to say that I did so well that my doctor no longer thinks I will need to take Lipitor. My valves seem to all flap when they’re supposed to (echocardiogram), and the nuclear stress test showed no obstructions whatsoever. But the clincher was that the calcium scan showed zero calcium. Yes, zero.

Given the high correlation between the presence of arterial calcium and propensity for heart disease in a country where heart disease is the number one killer (about every 25 seconds an American will have a coronary event) and a major medical expense, I wrote previously how it seemed penny wise and pound foolish for health insurers to not pay for calcium deposit screening. This test can offer actionable insight years  prior to the onset of ultimately costly symptoms. There is, reasonably speaking, savings of more than one kind to be had in this kind of knowledge: if  one knows, one can act in accord. I paid the $318 out of pocket. Now, it seems, despite the ostensible risk factors which may have counseled otherwise, I have spared my insurer the cost of a lifetime’s worth of Lipitor. And myself the burden of a lifetime’s worth of pharmaceutical dependence.

There’s a J.D. at the end of my name, not an MD, so I do not give medical advice. But I will say that the whole battery of tests was painless, congenial, and took about 4 1/2 hours spread over two visits– which is not a lot of time to invest in dispensing with the ominous unknown. Of those one every 25 seconds in America who have a coronary event, one every minute will die. Testing will help tell you where you stand, and you never know, you just might get some peace of mind.

A Trip to the Cardiologist, A Lipitor Future, and “Why Doesn’t My Health Insurer Want Me to Know if I’m Likely To Have a Heart Attack?”

I visited with a cardiologist last week. My inadvertent but no less harmful dalliance with two different kinds of drain cleaner having set off an entire chain of long past due check-ups. A little more than two years shy of fifty, I listened intently as I was told that although I had had a good run, a diet composed of grease, chocolate, quick carbs, coffee and unfiltereds was simply not going to cut it as I ventured into the last half of life (last third is more likely, but also more painful to consider– and I suppose for the doctor, harder to say).

I now look forward to a battery of tests. The first, done today, is designed to detect artery calcification: “Coronary calcium is specific for atherosclerotic plaque and can be detected with high sensitivity and accurately quantified by computed tomography (CT) to help predict future cardiac events related to coronary artery disease.” I had to pay for the test out of pocket as it seems my insurance company deems such screening unworthy of coverage– despite the tests highly vaunted predictive power. Quite a few people in this country die each year from heart disease–hard to understand how it wouldn’t be worth the $318 to know who was vulnerable–and if unchecked, destined for the very expensive Intensive Care Unit.

Tomorrow brings an echocardiogram and my first ever stress test. I readily assented to the tests as it is good, I suppose, to know where one stands. But in addition to testing and making dietary changes, the doctor also wants me to start taking Lipitor. A statin prescribed to lower cholesterol. I did not react well.  The prescription it seems is, in more than one sense, a life sentence.

And I am generally suspicious of the pharma zeitgeist. And terribly so as it concerns myself.

The prescription is not, in this instance, a treatment for an acute condition, it treats the endemic. If one has risk factors, it is prophylactic and is prescribed to reduce the risk of heart attack, stroke and other heart diseases. It is doubtful whether once I start taking this drug I will ever stop. There is no foreseeable time (while alive) that I will wish to stop reducing the risk of heart attack or stroke. And that I suppose is the essence of the onset of age– piling up prescriptions. A daily regimen that will follow one to the grave–only the dosages or the brand names changing as each day welcomes a regimen of pills. In short, this prescription feels like the onset of dependence. The forward guard, if you will. A harbinger of a pharmaceutical future.

Seeing my, shall we say, chagrin, the cardiologist told me that, like over 50% of the cardiologists he knows, he takes a statin. “We’ve seen the data.” Another recently told me  “Yeah, I take it. They should put it in the water.”

And so I will take this drug. But I am not happy. I am loath to think of myself in these terms. Only 12 or so years ago I played starting defensive tackle on a semi-pro football team. Soon I will be discussing my cholesterol numbers and God only knows what other numerical health indicators at cocktail parties.

The essence of good health is simply not having to think about it. It is not an issue. I have to think about it now. And I have a sneaking suspicion, that like when I first became a parent, the terms of my existence have just changed.

UPDATE

Photo credit to incurable_hippie.

Employers Adopt Chronic Disease Management Programs

Photo by wwarby via Flickr

Kaiser Family Foundation reports another option for employers attempting to keep health insurance programs affordable.

KFF states:

“Eighty percent of large U.S. companies this year are offering chronic disease management programs for workers in an effort to reduce health care costs, up from 51% last year, according to a new survey by Hewitt Associates, the Houston Chronicle reports. Hewitt surveyed 343 large companies and found that more employers are targeting costly chronic diseases — such as diabetes, heart disease, asthma and depression — rather than workers’ eating or exercise habits. Hewitt estimates that a company with 9,500 workers and 500 retirees younger than age 65 spends between $18 million to $22 million on health care just for those with diabetes.”

Companies are managing chronic disease “by offering employees personal health coaches, on-site health clinics and copayment waivers for needed medications.”

Compared to consumer-directed health plans, chronic disease management is a relatively uncontroversial approach to lowering health care costs for employers.  As we’ve noted in a recent post, “Twenty-five percent of the U.S. community population were reported to have one or more of five major chronic conditions.” Not only does chronic disease management focus on preventative care and employees’ long-term health, employers are saving money in the short-term.  The results, although varying, are generally successful, with employers “spending 10% to 30% less per year on medical care after two to five years (Sixel, Houston Chronicle, 4/2).”  The short-term savings could lead to healthier employees, higher productivity and long-term savings.

The Houston Chronicle reports that:

According to Joseph Jasser, regional medical director for Houston for Concentra, an industrial medicine and urgent care provider, “If you can change their lifestyle — cut out smoking, eat better and exercise — then they’re healthier and companies end up spending less for medical care.”