Category: statins

Dark Picture of Doctors

Seth Roberts20 Comments

A New York Times article about error in a risk calculator paints an unflattering picture of doctors:

1. The risk calculator supposedly tells you your risk of a heart attack, to help you decide if you should take statins. It overestimates risk by about 100%. The doctors in charge of it were told about the error a year ago. They failed to fix the problem.

2. The doctors in charge of the risk calculator are having trouble figuring out how to respond. The possibility of a simple retraction seems to not have occurred to them. As one commenter said, “That the researchers, once confronted with the evidence it was faulty, struggled with how to handle the issue is quite telling.”

3. In the comments, a retired doctor thinks the problem of causation of heart disease is very simple:

Statins . . . are only one component in the prevention and treatment of coronary artery disease. Item number one is to have a normal weight. Item two is never smoke. Item three is exercise. Four is to eat an intelligent diet. Five is to remove stress from your life as much as practical. If everybody did these five things (all of which are free), the incidence of coronary artery disease would plummet and many fewer would need statins.

This reminds me of a doctor who told me she knew why people are fat: They eat too much and exercise too little. She was sure.

4. In the comments, a former medical writer writes:

Several years ago, I wrote up, as internal reports, about two dozen transcripts recorded at meetings with local doctors that a major drug company held all around the country. The meetings concerned its statin. Two ideas presented at these meetings by the marketing team, and agreed with by the physician attendees, were: 1) the muscle pain reported by patients was almost never caused by the statin but was the result of excessive gardening, golfing, etc; 2) many children should be prescribed a statin and told that they would have to take the drug for life.

5. Another doctor, in the comments, says something perfectly reasonable, but even her comment makes doctors look bad:

I am a physician and I took statins for 2 years. Within the first 6 months, I developed five new serious medical problems, resulting in thousands of dollars spent on treatments, diagnostic tests, more prescription medications, and lost work. Neither I nor any of my 6 or 7 different specialists thought to suspect the statin as the source of my problems. I finally figured it out on my own. It took 3 more years for me to get back to my baseline state of health. I had been poisoned. I see this all the time now in my practice of dermatology. Elderly patients are on statins and feel lousy, some of whom are also on Alzheimer’s drugs, antidepressants, Neurontin for chronic pain, steroids for fibromyalgia. These poor people have their symptoms written off as “getting older” by their primary physicians, most of whom I imagine are harried but well intentioned, trying to follow guidelines such as these, and so focused on treating the numbers that they fail to see the person sitting in front of them. The new guidelines, with their de-emphasis on cholesterol targets, seem to tacitly acknowledge that cholesterol lowering has little to do with the beneficial actions of statins. The cholesterol hypothesis is dying. If statins “work” by exerting anti-inflammatory benefits, then perhaps we should seek safer alternative ways to accomplish this, without subjecting patients to metabolic derangement.

6. A patient:

My previous doctor saw an ultrasound of my Carotid Artery with a very small buildup and told me I needed to take crestor to make it go away. That was four years ago and I still suffer from some memory loss episodes as a result. The experience was terrible and he’s toast because he denied it could happen.

7. A bystander:

For the past couple of years my job has involved working with academic physicians at a major medical school. After watching them in action — more concerned with personal reputation, funding and internecine politics than with patients — it’s a wonder any of us are limping along. And their Mickey Mouse labs and admin organizations can barely organize the annual staff holiday potluck without confusion and strife. So these botched-up results don’t surprise me at all.

I am not leaving out stuff that makes doctors look good. Maybe this is a biassed picture, maybe not. What I find curious is the wide range of bad behavior. I cannot explain it. Marty Makary argued that doctors behave badly due to lack of accountability but that doesn’t easily explain ignoring a big error when pointed out (#1), an immature response (#2), a simplistic view of heart disease (#3), extraordinary callousness (#4) and so on. In her last book (Dark Age Ahead), Jane Jacobs wrote about failure of learned professions (such as doctors) to police themselves. Again, however, I don’t see why better policing would improve the situation.

Thanks to Alex Chernavsky.

Assorted Links

Seth Roberts7 Comments
  • Against the new statin guidelines. “For people who have less than a 20 percent risk of getting heart disease in the next 10 years, statins not only fail to reduce the risk of death, but also fail even to reduce the risk of serious illness.” This is one way of saying that although heart disease has been a top cause of death for more than half a century, doctors still have almost no idea how to prevent it. Vast amounts of money and time have been spent studying heart disease, but, judging by the great emphasis on an almost useless method of prevention (statins), the researchers who spent the money and time didn’t do effective research. Cancer could have a hundred different causes. Heart disease, probably not.
  • Follow mainstream food advice, increase risk of death. I’ve covered this earlier but it bears repeating. “There was a 30% greater risk of cardiovascular death among the people in the study who ate the cholesterol-lowering oil.” The cholesterol-lowering oil was safflower oil, high in omega-6. According to the Cleveland Clinic and many others, oils high in omega-6 are “heart-healthy”.
  • Use of yogurt to prevent infections in hospitals
  • Surviving your stupid stupid decision to go to graduate school (a reading list)

Thanks to Phil Alexander and Claire Hsu.

Assorted Links

Seth Roberts8 Comments

The Rise and Fall of Heart Disease

Seth Roberts11 Comments

Heart disease was once the number one killer in rich countries. Maybe it still is. Huge amounts of time and money have gone into trying to reduce it — statins, risk factor measurement (e.g., cholesterol measurement), telling people to “eat healthy” and exercise more, and so on. Unfortunately for the poor souls who follow the advice (e.g., take statins), the advice givers, such as doctors, never make clear how little they know about what causes heart disease. Maybe they don’t realize how little they know.

I encountered an ignorant-without-knowing-it expert after a talk I gave about the effect of butter on brain function. I found that butter improved my brain function (measured by arithmetic speed). I had been eating lots of butter for more than a year. A cardiologist in the audience said I was killing myself. He thought butter caused heart disease. I said that I had experimental data that butter was good for me. Easy to interpret. The notion that butter is bad has come from epidemiological (non-experimental) data, which is hard to interpret. The cardiologist said that the epidemiology has not been misleading. One sign of our correct understanding, he said, is that heart disease has declined. I said there were many possible reasons for the decline.

A 2012 paper called “An epidemic of coronary heart disease” by David Grimes, a British doctor, could hardly make clearer how little we know about the cause of heart disease. Grimes points out that before 1920 heart disease was almost non-existent, that it rose sharply from 1930 to 1970 and since 1970 has declined sharply, at roughly the same rate that it rose. Both the rise and the fall are mysteries, says Grimes, in agreement with what I told the cardiologist. The rise and fall contradict all popular explanations. Heart disease cannot be due to obesity or wealth — both increased substantially at the same time heart disease fell sharply. Nor was the decline due to government intervention:

The decline of CHD deaths in the UK was further described in a UK Government report of 2004, Winning the War on Heart Disease. In this report, the government predictably but undeservedly assumed responsibility for the decline. Clearly, the NHS [National Health Service] in the UK could not have had an international effect [the decline is international].

“There [has been] no obvious effect of statin therapy or other medical intervention,” Grimes continues. Yet statins continue to be prescribed in very high amounts and very great expense. The NNT (number of people you need to treat to save one life) is often in the thousands, he noted.

Those who complain about the high cost of health care fatally fail to grasp this enormous ignorance — about many things, not just heart disease — and its consequences. Reducing the cost of health care (reducing the cost of statins, for example) would improve health if cost were the only thing deeply wrong with our health care system. It isn’t.

“The $2.7 Trillion Medical Bill”

Seth Roberts12 Comments

The New York Times has started a series called Paying Till It Hurts about high medical costs. The first installment is called “The $2.7 Trillion Medical Bill” and is about the high cost of common procedures, such as colonoscopies, in the United States compared to other countries. (Which I blogged about quite recently.) The most extreme example is that a certain (unspecified) amount of lipitor costs $124 in the United States and $6 in New Zealand. Other treatments that cost much more in the United States include hip replacements and MRI scans.

This series might be a turning point, leading to government regulation of what health care providers can charge, which is how other countries control health care costs. To read the huge number of comments (already > 1000) is to see the suffering caused by these prices. One comment: “An acne medication was over $550 for a small tube of ointment. The [prescribing] Dr. had no idea it was that expensive.”

The high prices are the tip of the iceberg of American health care dysfunction. Less obvious is the poor research that sustains them. Acne is an example. It surely has environmental causes (probably diet). If we knew what those are, you wouldn’t have to pay anything to cure acne.

What Should Your Cholesterol Be?

Seth Roberts9 Comments

According to the Mayo Clinic website, lower levels of cholesterol are better. For total cholesterol, says the Mayo Clinic, below 5.2 mmol/L (= 200 mg/dL) is “desirable”. A level from 5.2 to 6.2 mmol/L is “borderline high”, and above 6.2 mmol/L (= 240 mg/dL) is “high”.

A 2011 study from Norway, based on 500,000 person-years of observation, found drastically different results. For both men and women, the lowest levels of total cholesterol (below 5.0 mmol/L) were associated with the most death. For men, the best level was intermediate — what the Mayo Clinic calls “borderline high”. For women, the safest levels were the highest.

If high cholesterol causes heart disease, as we are so often told, the pattern for women makes no sense. For a long time, experts have told us to limit egg consumption because eggs are high in cholesterol. However, a new study shows that egg consumption has no association with heart disease risk.

Via Malcolm Kendrick. I also like his post about whether statins cause muscle pain.

Undisclosed Risks of Common Medical Treatments

Seth Roberts10 Comments

Millions of tonsillectomies have been done, mostly to children. Were any of their parents told that tonsils are part of the immune system (taught in high school biology and known since the 1960s)? A Cochrane Review of tonsillectomies (the “highest standard” in evidence-based medicine) fails to mention that tonsils are part of the immune system. A recent study found tonsillectomies associated with a 50% increase in heart attacks. (I write about tonsillectomies here.)

Are tonsillectomies unusual? Several recent news stories suggest no, they aren’t. Failure to tell patients the full risks of medical treatment may be common:

1. Undisclosed risks of hernia surgery. From the Wall Street Journal: “More than 30% of patients may suffer from long-term chronic pain and restricted movement after surgery to fix a hernia . . . studies show.” The article says “many patients don’t consider” this risk — meaning they don’t know about it. A Berkeley surgeon named Eileen Consorti told me I should have surgery for a hernia I could not detect. I have previously written about her claim that evidence supported her recommendation when no such evidence existed — or, at least, no one including her has ever found it. I said I wanted to see the evidence because there were risks to surgery. She replied that none of her patients had died. I was shocked by the incompleteness of her answer. There are plenty of bad outcomes besides death — as the Wall Street Journal article shows.

2. Undisclosed risks of sleeping pills. A book called The Dark Side of Sleeping Pills by Daniel Kripke, a professor of psychiatry at UC San Diego, goes into great detail about risks of sleeping pills that few doctors tell their patients. For example, one study found that “patients who took sleeping pills died 4.6 times as often during follow-ups averaging 2.5 years [than matched patients who did not take sleeping pills]. Patients who took higher doses (averaging over 132 pills per year) died 5.3 times as often.” Insomnia alone was not associated with higher mortality. Tomorrow I will post Dr. Kripke’s answer to the question “why did you write this book?” Here is a website about the dangers of Ambien.

3. Undisclosed risks of anticholinergic drugs. From the NY Times: “After following more than 13,000 British men and women 65 or older for two years, researchers found that those taking more than one anticholinergic drug scored lower on tests of cognitive function than those who were not using any such drugs, and that the death rate for the heavy users during the course of the study was 68 percent higher. That finding, reported last July in The Journal of the American Geriatrics Society, stunned the investigators.” Anticholinergics are “very very common” said a researcher. They include many over-the-counter drugs, such as “allergy medications, antihistamines and Tylenol PM”.

4. Undisclosed risks of statins. A recent NY Times story says “the Food and Drug Administration has officially linked statin use with cognitive problems like forgetfulness and confusion, although some patients have reported such problems for years. Among the drugs affected are huge sellers like Lipitor, Zocor, Crestor and Vytorin.” Prior to this official linkage, the reports of forgetfulness and confusion were mere anecdotes that evidence-based medicine proponents ignore and tell the rest of us to ignore.

5. Undisclosed risks of metal-on-metal hip replacements. They leak dangerous amounts of metal (e.g., cobalt) into the rest of the body. “Despite the fact that these risks have been known and well documented for decades, patients have been kept in the dark,” says a recent article in the BMJ. By 2007, the danger was so clear that a British regulatory committee said that patients must sign a form saying they’ve been warned. This didn’t happen — a surgeon told the BMJ that “surgeons were unaware of these discussions.” Other materials could have been used.

These six treatments (tonsillectomy, hernia surgery, sleeping pills, anticholinergic drugs, statins, and hip replacement) are so common they raise a scary question: What fraction of the risks are patients usually told?

The surgeon or drug company gets paid no matter what happens to you. Malpractice lawsuits are very rare on a per-patient basis — and no one will be sued for performing a tonsillectomy on a child who gets a lot of colds or prescribing sleeping pills to someone who has trouble sleeping. In a Freakonomics podcast, Steve Levitt said that doctors terrify him. And his father is a doctor. Given the undisclosed risks of common treatments, he is right to be terrified.

Thanks to Allan Jackson, Alex Chernavsky and Tim Beneke.

Hidden Side Effects of Statins and How Easily You Can Uncover Them

Seth Roberts6 Comments

In 2009, a British rheumatologist named Andrew Banji wrote about the hidden side effects of statins in the Daily Mail:

I discovered the link between statins and rheumatic side-effects quite by chance. My attack of tendon inflammation occurred at the front of my shin – a highly unusual place for tenosynovitis – so I decided to do some research into what could have triggered this. I was amazed to discover the only other related case was linked to a patient on statins.

Following a high cholesterol-reading of 9.2 a couple of months before, I’d been put on the drug. Intrigued by the connection, I decided to stop taking my statin to see what happened. Within a couple of weeks, the pain had gone.

I went back to my GP and, over successive months, tried various statins, including rosuvastatin which is one that is often prescribed.

Each form of the drug caused terrible problems, including night cramp, muscle pain, severe muscle disorders known as myopathy and general fatigue. In fact, I became so tired I couldn’t lift anything when I was gardening or even walk the half-mile from my home to the center of town.

Yet whenever I halted the medication, my symptoms disappeared within a few weeks. . . .

I began to realize many of my patients with musculoskeletal conditions such as polymyalgia – pain, stiffness, and tenderness in the muscles – were on statins. When I advised them to stop taking their medication, their problems went away.\

By 2009, statins were perhaps the most heavily prescribed drugs ever, making tens of billions of dollars for drug companies. Yet this story shows that at that point a doctor who was taking statins was not yet aware of major common side effects. How convenient for drug companies. The story also shows that patients with a variety of muscular problems had to be told by a doctor to stop taking their statins to find out if the statins were causing the problem. That should have been common sense. On a more positive note, this story shows how easily some health problems can be fixed (“when I advised them to stop taking their medicaiton, their problems went away”).

Assorted Links

Seth Roberts1 Comment
  • Five quantified-self stories
  • False Alzheimer’s diagnosis. “Alzheimer’s symptoms such as confusion, memory loss and personality changes also can be side effects from medication—even commonly used drugs. For example, the entire class of anticholinergic drugs, which includes many antihistamines, antianxiety drugs, muscle relaxants and sleeping pills . . . Cholesterol-reducing statins have also been linked to brain fog in some people. In many cases, the cognitive symptoms vanish when medication is stopped. “I have had people referred to me with a clear history of dementia and when I started to peel back the medications, they were much better,” says Gary Kennedy, chief of geriatric psychiatry at Montefiore Medical Center in the Bronx, N.Y.”
  • Ancestral Health Symposium 2012 (Boston) recaps. I thought Robb Wolf’s talk was excellent. Jay Stanton had original ideas about weight control. Most of the other talks, not so much.

Assorted Links

Seth Roberts5 Comments
  • One of my Tsinghua American colleagues writes an op-ed: “China wants you. Job prospects are abundant.”
  • Robert Anton Wilson’s skepticism about skeptics. “Those people claim to be rationalists, but they’re governed by such a heavy body of taboos. They’re so fearful, and so hostile, and so narrow, and frightened, and uptight and dogmatic. . . . None of them ever says anything skeptical about the AMA, or about anything in establishment science or any entrenched dogma.” I agree. They should be called one-way skeptics.
  • Excellent Vanity Fair article about Occupy Wall Street. Better than The New Yorker‘s article covering similar stuff.
  • The many side effects of statins. I am impressed by the new way of learning about drug side effects.

Thanks to Ryan Holiday and Gary Wolf.