Updating the Biases by Pat Conrad MD

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Last week Doug shared a piece called “Number Needed to Treat”, in which he noted that as many patients were harmed as were helped by statin therapy.  Now MSN ‘Healthy Living’ has this headline:  “US doctors urge wider use of cholesterol drugs.”

The lead-off grabber:  “(AP) The nation’s first new guidelines in a decade for preventing heart attacks and strokes call for twice as many Americans — one-third of all adults — to consider taking cholesterol-lowering statin drugs.”  Whose guidelines?  Why, the American Heart Association and American College of Cardiology, veritable Walter Cronkites of U.S. medicine, unimpeachable in their credibility.  Now instead of focusing on set lipid levels, they are focusing on four at-risk patient groups:

—Preexisting heart disease.

—Those with LDL of 190 or higher.

—People ages 40 to 75 with Type 2 diabetes.

— People ages 40 to 75 who have an estimated 10-year risk of heart disease of                                                                                                             7.5 percent or higher.

The heart gang is also pro-exercise, pro-aspirin, and pro-healthy diet.

As a former med student and resident, I know this would be my cue to memorize the new guidelines for morning rounds, and start beating my clinic patients into these newly shaped molds  – for their own good.

“The government’s National Heart, Lung and Blood Institute appointed expert panels to write the new guidelines in 2008, but in June said it would leave drafting them to the Heart Association and College of Cardiology.”  (Is there anything the government doesn’t have an [expletive] panel on?)

The story shares that “under the new advice, 33 million Americans — 44 percent of men and 22 percent of women — would meet the threshold to consider taking a statin. Only 15 percent of adults do now.”  Admittedly I stink at math so check me, but that seems to be an increase of over 100%.  Seriously?!

I was also had to chew a little harder than some of my classmates in medical statistics class, but I do remember one lesson very well:  the most important fact or feature in any study is who paid for it.  Credit is due to the article for pointing out that “Roughly half the cholesterol panel members have financial ties to makers of heart drugs, but panel leaders said no one with industry connections could vote on the recommendations.”

Understand, I am not bashing these guidelines.  They purport to advance statins as an agent to treat patients, as opposed to correcting patient lab values.  This may indeed be sincere and based on good science, and if so, laudable.  Or can such guidelines, which arose from government and industry funding, be convincingly free of bias when a third of a population (admittedly often the chubby, out of shape, hyperglycemic third) is deemed in need of intervention?  Are we seeing mass confirmation bias?  Am I guilty of, I don’t know, “bias” bias if I still refuse to take the damn stuff?

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  3 comments for “Updating the Biases by Pat Conrad MD

  1. T Newberry
    November 20, 2013 at 10:47 am

    Pat, I’m with you. It was just coincidental for those of us who read this blog to see that NNT statistic on statins and then almost immediately see this news. But, wow it sure does make the entire medical community look out of touch.

    This may or may or may not be a perfect metaphor: Your bedroom is filling up with smoke. Your solution is to open a window and put in a fan to blow in fresh air. This may be a perfect metaphor because taking a statin is like completely ignoring the fire that is producing the smoke. It may not be a perfect metaphor because smoke can be deadly but there is really no evidence that cholesterol is (it may be, there is just no evidence to prove that).

    I agree with Kurt. The real danger of statins is that they give people a false sense of security and a perceived license to keep living an unhealthy lifestyle.

  2. DrHockey
    November 20, 2013 at 9:25 am

    Just add the statins into the water supply, like fluoride.

    Next discussion — when should we start adding hypoglycemic agents to the water supply?

  3. Kurt
    November 17, 2013 at 8:05 pm

    Weeeeellllllll Pat,

    I do think if your profile was way the heck out of bounds, you’d be better off taking ’em and accepting the risk. On the other hand, I think we all know that folks take the drugs so they can continue to eat the high fat
    garbage that got them in trouble in the first place. Those that do make diet changes get by with no or less drug.
    Personally, I was at a BMI of 27 and cut my calories to get to the point when I was a senior in high school.
    Yeah, 27 isn’t bad but I wanted to see if I could do it since I bitch at everyone else to. As an aside, my lipids dropped from the point to where one needs to take notice to absolutely perfect. Wished I had time to exercise.
    Spent time doing the bullshit paperwork today and incidentally reviewed a faxed form from an insurer that said one of my NP’s patient’s needs to be on a statin simply because she is fat and diabetic. Well y/t (yours truly) scoped out the record and yes, she’s fat, yes she’s on metformin, no she doesn’t smoke, no she doesn’t have evidence of PVD , yes she’s 42 and wow, her lipid profile and glyco look good. As far as I’m concerned F-you the insurance company.
    Oh, I had a fellow who we’ve battled trying to get a tolerable statin going for him. Had atrocious lipids
    but no vascular events. Was using QOD dosing and tolerating it well until out of the blue had rhabdo and liver enzyme elevations. Cardiologist told me that the shit is so safe we don’t “have to” do enzymes anymore.
    Yeah sure. (She said that very facetiously to me and still exercises caution like I do.)

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