What’s this? The late, great Tommy Cooper being posthumously recruited to the British Heart Foundation’s ‘be-good-and-take-your-medicine’ campaign?
It’s Tommy’s job to encourage us all to take our daily statins. Because official wisdom says that the wellbeing of the population-at-large depends on everyone taking their pills – even if they, individually, will probably not benefit.
The general idea has a distinct logical elegance – as this small ‘thought experiment’ illustrates. Imagine that you are presented with 50 people in Trafalgar Square at 11.30 am and told that it is vital that one of them is at Euston at 12 noon. Thinking that you’d better call that person a cab, you ask: “which one?”. But now imagine that this important piece of information is not available – you just know that ONE of them has to be there. The only sure way of meeting the demand is to call a small fleet of cabs and take all 50 people to Euston. This may have involved 49 of them in a wasted journey – but at least that vital (but still anonymous) 50th person will definitely be there.
Welcome to the world of population risk treatment. The people in Trafalgar Square are a national population who, on average, have a cholesterol level in their collective bloodstreams that (in an individual) would be associated with elevated risk. But by no means all of them will have a coronary. In fact, only a few of them will – we just don’t know which ones. The only sure way of successfully treating the odd one that will eventually have the coronary is for all of them to take their daily statin pills.
And that’s where Tommy, his trademark fez and his immortal catchphrase come in. I suppose that the British Heart Foundation think that we are more likely to be influenced by him than by Andrew Lansley or the CEO of BigEvilPharma Ltd. (To be fair, they might actually have a point there…!)
But had Tommy still been with us he might have noticed a recent email from Medscape in his in-box. And he might, like me, have been intrigued by the article entitled “Safety of Statins – an Update: Muscle Toxicity”. And after reading it and surfing the related links for a while, he might have felt like ringing his agent to check on the ethics of what he was getting in to.
Because there’s lots of debate about the less pleasant effects of taking statins. If taking a daily pill were 100% guaranteed to have absolutely no effect except stop a heart attack in someone who was definitely going to have one, then the “upside/downside” calculation would, be an easy one. Take the pill – it might save your life. OK, some people (you know – the awkward squad who were brought up on a diet rich in Illich and Foucault) might baulk a bit at the medicalisation of a previously normal life – but let’s forget the extremists for a minute.
The problem is that, far from being guaranteed ‘100% safe’, the pills have an unfortunate propensity to bring about a range of nasty experiences. Luckily, RCT’s have shown that this is likely to happen in only a very small percentage of people. Phew! So the mass treatment of the population gets the green light – because the overall good (preventing a number of heart attacks) trumps the overall bad (muscle aches, memory losses, damaged kidneys).
So far so good. But – hang on a minute. What if YOU are one of the people who wasn’t going to have a heart attack anyway? And what if YOU get aching limbs because of statin-induced myopathy? Suddenly the advice that Tommy and the BHF are peddling doesn’t look so clever, does it?
Now, as any epidemiological clever-dick will tell you, it’s all a numbers game. You’ve got to play the percentages. But you’ll have to have a lot of faith in the numbers, because you’ll never actually know which one of the Trafalgar Square/Euston Station people you are. All you will know is that you are on that mass taxi ride.
At this point you and your late pal Tommy Cooper might choose to get seriously interested in the statistics and how, exactly, they are arrived at. And by a quick perusal of the Medscape article you find that things aren’t as straightforward as they seem. In fact you read that, while RCT’s indicate that a tiny 0.01% of statin-takers get muscle problems, observational studies of real populations suggest that the figure might be a whopping great 10%.
A key reason for this disparity is hinted at in Paul Philips’ fascinating 2009 article in Annals of Internal Medicine entitled “Balancing Randomized Trials With Anecdote”. Philips thinks that one reason might be that, because of stringent inclusion criteria,
“The older, sicker patients receiving multiple medications, which we commonly see in practice, are systematically excluded from efficacy trials.”
In other words, the pharma industry are cherry picking patients to make sure we only get the good news. All together now…. “just like that”.