Mainstream media coverage of healthcare topics is often prone to sensationalism, designed to invoke attention and reactions, 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 popularity and many media articles express negativity about their usefulness.
Why the controversy?
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 be variable according to the type of statin given and the dosage of the statin.
The systematic review and meta-analysis looked at previous systematic reviews on Medline and other reputable databases up to August 2020. Studies included randomised controlled trials in adults with no history of cardiovascular disease, where statins were compared with non-statin controls, or different types or dosages of statins were compared. The primary outcomes were 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 both self-reported muscle symptoms and liver dysfunction in 21 trials, renal insufficiency in eight trials and eye conditions in six trials.. However, they were not found to be associated with any confirmed clinical conditions such as muscle disorders or diabetes. While not discounting patients’ experiences, there was a clear distinction between what a person thought they were experiencing based on their symptoms and actual disorder. Therefore, increased risks were not found to outweigh the reduction in the risk of major cardiovascular events.
However, 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 team found that other dose-response relationships for the other statins and adverse effects were inconclusive.
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 on the whole favourable (Cai et al, 2021). However, there is an increased risk of liver dysfunction with statins and therefore generally routine monitoring of liver function throughout treatment is a valid clinical intervention also recommended by companies that produce statins. The researchers 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.
While statin efficacy generally outweighs risk, there is a clear need for research to help improve adherence to these medications, so that patient characteristics can be identified that are significant to the minor risk 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 to detect the rarer adverse events that can occur on a minor scale.
Social media influence
Rodriguez (2020) commented on a retrospective study carried out by Golder et al (2020) examining Twitter posts (‘tweets’), in order to identify patients’ negative beliefs and experiences with statins. This type of research is useful for highlighting what people across the ‘real-world’ spectrum think and feel about such treatments. Posting online allows a level of anonymity and thus a freedom to share experiences, ideas and opinions. However, there is the potential for the spread of inaccurate information as well, sometimes posted across multiple accounts created by one person, resulting in bias.
Rodriguez (2020) commented that adherence to statins remains low despite their importance for primary and secondary cardiovascular disease prevention. Investigators identified tweets that mentioned any of eight specific statin drugs from 2013 to 2018. They used qualitative research methods to classify the tweets thematically and by who likely posted them. In total, Golder et al (2020) examined 11 852 Tweets, discovering that 44% were health-related, and 35% were fact-based, often linking to published studies. Of the health-related posts, 33% were found to be posted by a statin user. This was determined by whether the Twitter user had employed first-person pronouns. Of these, 16% stated that they had experienced an adverse event. Of the health-related posts, 21% were categorised as beliefs surrounding statins rather than based on factual evidence and 20% described harm or mistrust of the medical profession or the pharmaceutical industry (Golder et al, 2020).
Rodriguez commented that despite statins being safe and generally well-tolerated, inaccurate information online continues to affect patients adherence to treatment. The study by Golder et al (2020) provides a window into what patients may be thinking, but not disclosing to their health professionals and prescribers. Such insight may aid health professionals to open up discussions with patients about information they are obtaining through their own research that they can have any questions answered, misconceptions clarified and feel supported to make choices based on a fuller more complete picture.
NICE guidance
The National Institute for Health and Care Excellence (NICE) (2021) recently recommended the wider use of statins for the prevention of cardiovascular disease. Guidelines note that GPs should offer atorvastatin 20 mg for the primary prevention of the disease to people identified as having a 10% or greater risk of developing cardiovascular disease within the next decade. Patients who have type 1 or 2 diabetes should be offered 20 mg atorvastatin for the primary prevention of cardiovascular disease, and those with established cardiovascular disease may require 80 mg.
NICE (2021) also recommends that doctors discuss the benefits of lifestyle modifications with their patients before commencing statin therapy, and that the QRISK2 assessment tool be used to establish cardiovascular risk in all patients. GPs are facing ever-increasing demand and have huge numbers of patients. However, NICE states that this new 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).
Conclusion
While the benefits of statins are believed to outweigh any risks, barriers to their use remain in the community, and while the internet can be a valuable resource for patient education, it can also be a source of misinformation from less credible sources. National guidance has been updated to reflect the importance of statin use, promoting GPs to risk-assess patients and increase statin prescriptions for those who could benefit.