Statins are the most commonly prescribed, and perhaps one of the most controversial, drugs in the UK. In 2018, 7.9 million people took them, and 71 million statin prescriptions were dispensed (Nuffield Department of Population Health, 2021).
While there have been multiple negative headlines that may have influenced uptake of this potentially life-saving drug, multiple national bodies including the NHS and the National Institute for Health and Care Excellence (NICE), as well as charities such as the British Heart Foundation (BHF) and many other organisations, are in strong favour of the use of statins to reduce the risk of cardiovascular events such as myocardial infarction (MI) and stroke (BHF, 2021). The BHF notes that the nature of how the drugs are used − as a preventive treatment prescribed at scale − can influence controversial headlines and multiple articles on the subject across the media sector. This can impact how people react to being prescribed these medications and to their medication adherence. Patients' concerns may feel irrational to healthcare professionals who know the research, but they are very real to the average person who does not work in the healthcare or medical sector, and who may have read about extremely worrying (though extremely rare) side effects. As such, adherence to such medication is an issue at times because of the influence of articles read by such patients. The BHF (2021) therefore highlights how crucial it is for health professionals to ensure that patients are well informed and are involved in the decision-making process regarding their treatment.
Recent research
A recently published study evaluated incident cardiovascular disease (CVD) and the initiation as well as subsequent adherence to statin treatment for the treatment of primary prevention in those who have just been diagnosed with high cholesterol.
Ryou et al (2021) carried out a population-based retrospective cohort study using the National Health Insurance Service-Health Screening Cohort (NHIS-HEALS) from the Republic of Korea. A limitation may therefore relate to the generalisability of this study to other populations. The study was large, however, incorporating 11320 people with no previous history of CVD incidence, all between 40 and 79 years of age. All participants had an elevated total cholesterol level (more than 240 mg/dl) and had started statin treatment within 24 months of the national health screening from 2004 to 2012 identified in the NHIS-HEALS. The primary outcome, CVD, was defined as first-ever admission or death due to ischaemic heart disease, acute MI, revascularisation or stroke.
Ryou et al (2021) found that early statin initiation significantly lowered the risk of CVD outcomes when compared with starting the treatment late. Of those who started the treatment early, statin discontinuers were observed to have a significantly higher risk for CVD in comparison with persistent users, while statin re-initiators had an attenuated risk increase. The authors concluded that of statin users with newly diagnosed hypercholesterolaemia, early statin initiation is associated with lower CVD risk compared with late initiation. Furthermore, statin discontinuation is associated with an increased risk of CVD, but re-initiation attenuated the risk.
This research is important to mention to patients who feel they do not need statins based on a longstanding view they may have based on the influence of the mainstream media on the issue some years ago, or those who simply do not know the facts and may not like the idea of taking medication.
The BHF (2021) describes the way negative headlines affecting the likelihood of patients stopping statins can actually be quantified. In 2016, a BHF-funded study found that patients were 11% and 12% more likely to stop taking statins for primary and secondary prevention respectively, following a period in which statins received extensive negative media coverage (Matthews et al, 2016). The BHF (2021) also points to a Danish study published in 2015 that found that every negative nationwide news story meant that people were 9% more likely to stop taking statins, which then led to a 26% greater risk of MI and an 18% increase in the risk of cardiovascular mortality in those who stopped taking the medication (Nielsen and Nordestgaard, 2016).
The rise in statin use is significant, and can be acknowledged, but there is nothing necessarily negative about this. The amount of statin prescriptions has gone up by 46% since 2008. However, the cost of dispensing statins decreased by nearly £400 million in that time to just £96 million, falling 79% in just 10 years (BHF, 2021). This was owing to commonly used drugs at that time coming off-patent, meaning the drug company who originally produced and created atorvastatin and rosuvastatin, for example, significantly reduced the cost for others to buy the drug once its patent had ended.
Reassuring patients
Patients may also feel reassured of the safety of statins as a result of pointing out that NHS England (2019) is considering making them available over the counter at high dosage, so no prescription is required. Already, low-dose statins are available over the counter (BHF, 2021). In the NHS Long Term Plan, the NHS has set out the desire to prevent 150 000 MIs and strokes, and this could be one way of tackling this. It is difficult to access the GP at times and some patients simply do not like attending their GP for multiple reasons. It may therefore be safer to make these drugs more readily available without prescription but instead with a discussion with the pharmacist, so that patient uptake may be higher, particularly among groups of people who do not routinely attend the GP or blood tests.
According to NHS England (2019), up to two-thirds of people at high risk of MI and stroke do not take statins but could benefit from doing so. Meanwhile, the BHF recommends informing patients of ‘absolute benefit’, which involves telling the patient about advantages and disadvantages. They can then feel involved in a shared decision-making process. It is important to be sensitive about the matter as there are early side effects such as muscle pain, for example. The BHF (2021) therefore recommends expressing the potential benefit not just in relative terms, but also in terms of absolute reduction in 5-year risk.
Risk of major cardiovascular events is reduced by around 25% for each mmol/litre reduction in low-density lipoprotein (LDL) after taking statins, according to one review. This can also be expressed by saying that lowering the LDL cholesterol of 10000 patients by two mmol/litre over 5 years ‘would typically prevent major vascular events from occurring in about 1000 patients'. This means that 10% of people treated would benefit: an ‘absolute benefit’ of 10%. For people taking statins for secondary prevention, the absolute benefit is around 5% (BHF, 2021). However, this information may feel heavy for patients to take in and counselling about prescribing such a medication can be tailored to the individual.
It is hoped that with well-informed patients, involved in shared decision-making and empowered to make the right choice about their treatment, the best outcomes for them can be achieved.