Just when we thought we had clarity on statin safety …
Last week’s leading health headline was a startling new finding that statin use increases the risk for diabetes mellitus (DM) in post-menopausal women by 50 percent, from six percent to nine percent.
While the data source -- the Women’s Health Initiative -- is an observational rather than a prospective study, the finding persists in a variety of patient subgroups, and even after the authors adjusted for baseline patient characteristics. This makes it unlikely that the increase in DM rate is due to women’s pre-statin risks of developing DM. Since diabetes is probably the single most important cardiac risk factor -- often considered the equivalent of a first MI in certain predictive models -- this news was both unsettling and perplexing. How might physicians and their patients interpret and act on this new information?
We were curious, so last week we conducted a small survey of full-time, office-based U.S. primary care physicians (PCPs) from the Epocrates physician panel* to test our hunches. Seven out of 10 PCPs had heard the recent mass media news coverage and, as a point of interest, two-thirds of them found the coverage “sensational” rather than “balanced/informative” -- despite the fact that clinicians interviewed on NBC Nightly News emphasized that they expected to keep their patients on statins.
Certainly, the news got patients’ attention. As of our survey date, at least one-third of PCP offices had received inquiries from statin patients. Balanced coverage or not, this sort of news event raises alarms, and it’s impossible for patients to draw implications on their own. What should patients, in fact, make of it?
Actually, nothing's really changed ...
On average, a post-menopausal woman with elevated lipids is still better off taking a statin than not taking one. The authors of the study concluded that current ADA guidelines should not change because “statins significantly benefit vascular and secondary prevention … in diabetic populations with rates comparable with those without DM.” The conclusion remains: Net morbidity and mortality decline on a statin despite a 50 percent increase in diabetes diagnoses among a key population of statin users. We’re left to do the forensics on how and why statins raise blood glucose in some patients, but there is no urgent need to reassess the risk-benefits.
Presumably, many or most of the patients who made calls were encouraged to stay on statins. But many patients didn’t call, and even those reassured by their physicians, now or in the future, have one more concern nagging at them when they consider just how adherent they want to be with statin therapy.
What physicians are actually worried about
Our survey suggests that primary care physicians are worried less about these new findings than they are about how patients will react, since physicians have always struggled with the challenge of enforcing statin compliance. Six in 10 surveyed PCPs expressed concern that news of the results will erode patient compliance with statin therapy, and one-third anticipate difficulty keeping some patients on their statin medication altogether. In fact, some PCPs predict that defections in their practice may number in the hundreds. If true, this finding may have set cardiovascular prevention back a few paces, just when we might have imagined that statin phobia was a dwindling issue.
Keeping it real
So what’s to be done? Physicians will need to stick to the evidence and stick to their guns when patients challenge the safety and relevance of statin therapy. But now more than ever, they will also need to remind patients that statins can’t be seen as license to eat what they want, absolving them of all responsibility for self-discipline.
We’re also curious about another aspect of last week’s media flurry. Coverage of the study results was much more prominent on television than in print media. Morning shows and evening news coverage was full of discussions by anchors and physicians. On the other hand, The New York Times made no mention of the study at all, as far as we can find. It leads us to speculate that medical journalists who scan for new data concluded that attention to the study wasn’t worth the fuss. It also suggests that what physicians found so sensational about last week’s coverage may have been simply seeing it on the six o’clock news. TV seems more sensational than print, no matter how circumspect the coverage.
In any case, the newest study findings are one more reminder that drugs are complex tools with plenty of unanticipated effects (as if we needed it that reminder). And the statin link with diabetes is yet another item to add to the long list of issues that require open, fruitful dialogue between patients and physicians about the risk-benefits of any therapy. The good news here is that the big picture evidence is still clear on statins. Physicians remain fully convinced. Now, they just need to keep an eye out for waning conviction among their patients.
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*Epocrates Honors Market Research program has the largest opted-in, verified physician panel in the industry with over 225,000 U.S.-based physicians, as well as 885,000 allied healthcare professionals.