Why was there no declaration on conflict of interest?I don't really understand the need if they tell you which parties are providing assistance with the study. How would that help the reader? Obviously on some level yes there is a potential for a conflict of interest but as I already said they do their best to try and remove that as much as is humanly possible. Its left to the reader to factor this in to their interpretation of the data since there is no way anyone could ever quantify how much influence there might have been. To ask the authors to try an quantify it would be fruitless since they believe rightly or wrongly that they have eliminated this with their efforts. As I stated, what other option do you have. Either trust the system we have and always have some level of skepticism or find a better approach which no one has come up with yet. Relying on anecdotes and personal experience would be far worse. There are checks and balances. No study stands on its own. Other researchers are always trying to reproduce the results from any sufficiently important study such as these. If the results are reproducible then we have greater confidence in them. If not then we have to question them.
The emphasis on keeping LDL low (below 130 or 160) is questionable. So, in 3) even with no risk factors, statins would be prescribed. Is it necessary to have low LDL for a proven therapeutic effect or is it just because statins can do that?Treating to keep the LDL below 130 or 160 is questionable NOW because we have more information which is why the recommendations were changed. They were reasonable at the time the original recommendations were authored just as treating to keep your total below 200 was reasonable at one time and now we know better. Medicine like all of science evolves as knowledge is accumulated. Thats the way it has to be unless you are an omnipotent god who comes into the world knowing everything there is to know.
Being "anecdotal" does not mean it can be dismissed.It can and should be dismissed when there is objective evidence that the conclusion being drawn is inaccurate.
From the same article cited in post 29:Of course not and he is not the originator of this idea. All he is dong is repeating current medical theory of atherosclerosis and the mechanism by which statins most likely work. If you read my first post you would see that I said exactly the same thing in there. This is the standard medical theory of atherogenesis and rationale behind statin use today.I am a vascular surgeon. Before founding a private clinic in Dorset 11 years ago, specialising in varicose veins, I worked in the NHS for 13 years. Back then, I didn’t question medical guidance on cholesterol, and thought statins were a wonder drug. And so they probably are, for men who have heart disease — not necessarily because they lower cholesterol, but because they may cut other risks such as the inflammation-marker CRP.He is not just a layman.
Because most doctors just like most people have a difficult time changing their world view quickly. We have run into exactly the same issue with PSA's and Mammograms. I was trained to do these test as part of a routine exam in the correct age groups. More recently studies have since shown that PSA's do not decrease death rates or prolong life but we are having a very tough time convincing doctors to eliminate them from the standard blood work they do on men even though they have nothing to gain by doing them. Mammograms have similarly been shown not to reduce death rate in women under 50 but when suggestions were made to delay regular screening from the current standard of 40 to 50 years of age there was a tremendous outcry from not only the public but physicians as well...even among physicians who do not stand to make a profit from this practice. Several large studies have shown that home glucose monitors do nothing to improve outcomes for Type 2 diabetics who are not on insulin. I have been campaigning for years to eliminate the practice of home glucose testing in this group but have run into tremendous resistance from colleagues because their brain tells them it should be helpful and they have a difficult time believing the data. People don't change easily.. even the smart ones. Doctors are human and sometimes subject to the same foibles as the rest of humanity.GPs are, by definition, generalists. They don’t have time to read and analyse data from every paper on every medical condition. Even so, in a recent survey by Pulse magazine, six in 10 GPs opposed the draft proposal to lower the risk level at which patients are prescribed statins. And 55 per cent said they would not take statins themselves or recommend them to a relative, based on the proposed new guidelines.Why are these doctors so recalcitrant?
I don't really understand the need if they tell you which parties are providing assistance with the study. How would that help the reader? Obviously on some level yes there is a potential for a conflict of interest but as I already said they do their best to try and remove that as much as is humanly possible. Its left to the reader to factor this in to their interpretation of the data since there is no way anyone could ever quantify how much influence there might have been. To ask the authors to try an quantify it would be fruitless since they believe rightly or wrongly that they have eliminated this with their efforts.A declaration of conflict of interest is important to show no bias in the study. For instance, if pharmaceutical companies provided the majority of the funds, then the study is not independent and the findings are questionable and not credible. OTOH, not to declare conflict of interest implies possible hidden agendas which cannot be disclosed.
As I stated, what other option do you have. Either trust the system we have and always have some level of skepticism or find a better approach which no one has come up with yet. Relying on anecdotes and personal experience would be far worse. There are checks and balances. No study stands on its own. Other researchers are always trying to reproduce the results from any sufficiently important study such as these. If the results are reproducible then we have greater confidence in them. If not then we have to question them.From this article here]
A competing interest—often called a conflict of interest—exists when professional judgment concerning a primary interest (such as patients' welfare or the validity of research) may be influenced by a secondary interest (such as financial gain or personal rivalry). It may arise for the authors of an article in The BMJ when they have a financial interest that may influence, probably without their knowing, their interpretation of their results or those of others. We believe that, to make the best decision on how to deal with an article, we should know about any competing interests that authors may have, and that if we publish the article readers should know about them too. We are not aiming to eradicate such interests; they are almost inevitable. We will not reject your article simply because you have a conflict of interest, but we want you to make a declaration on whether or not you have competing interests. (We also ask our staff and reviewers to declare any competing interests.)
Treating to keep the LDL below 130 or 160 is questionable NOW because we have more information which is why the recommendations were changed. They were reasonable at the time the original recommendations were authored just as treating to keep your total below 200 was reasonable at one time and now we know better. Medicine like all of science evolves as knowledge is accumulated. Thats the way it has to be unless you are an omnipotent god who comes into the world knowing everything there is to know.If keeping the "LDL below 130 or 160 is questionable NOW", then why should statins be prescribed at all for 3)?
It can and should be dismissed when there is objective evidence that the conclusion being drawn is inaccurate.That should be determined on a case by case basis, not whole scale per se.
Of course not and he is not the originator of this idea. All he is dong is repeating current medical theory of atherosclerosis and the mechanism by which statins most likely work. If you read my first post you would see that I said exactly the same thing in there. This is the standard medical theory of atherogenesis and rationale behind statin use today.Why did he stop taking statins?
Because most doctors just like most people have a difficult time changing their world view quickly. We have run into exactly the same issue with PSA's and Mammograms. I was trained to do these test as part of a routine exam in the correct age groups. More recently studies have since shown that PSA's do not decrease death rates or prolong life but we are having a very tough time convincing doctors to eliminate them from the standard blood work they do on men even though they have nothing to gain by doing them. Mammograms have similarly been shown not to reduce death rate in women under 50 but when suggestions were made to delay regular screening from the current standard of 40 to 50 years of age there was a tremendous outcry from not only the public but physicians as well...even among physicians who do not stand to make a profit from this practice. Several large studies have shown that home glucose monitors do nothing to improve outcomes for Type 2 diabetics who are not on insulin. I have been campaigning for years to eliminate the practice of home glucose testing in this group but have run into tremendous resistance from colleagues because their brain tells them it should be helpful and they have a difficult time believing the data. People don't change easily.. even the smart ones. Doctors are human and sometimes subject to the same foibles as the rest of humanity.Would you take statins or recommend them to your friends and relatives as in 3)?
A declaration of conflict of interest is important to show no bias in the study. For instance, if pharmaceutical companies provided the majority of the funds, then the study is not independent and the findings are questionable and not credible. OTOH, not to declare conflict of interest implies possible hidden agendas which cannot be disclosed.Nothing is hidden. They are telling you who sponsored the study. Its up to the reader to decide whether that may result in a conflict of interest. Asking the writer to make that decision is like asking someone accused of a crime if they are guilty. It makes no sense.
If keeping the "LDL below 130 or 160 is questionable NOW", then why should statins be prescribed at all for 3)?I assume by "3)" you are referring to the current recommendation to treat people who have an LDL greater than 190? You seem to be misunderstanding things here. No one is saying that cholesterl levels aren't important. What we are saying with the new recommendations is that if someone has an average risk based on other risk factors an LDL of 190 or above is in itself enough of a risk to justify statin use
Anecdotal stories are generally used in arguments to undermine and misdirect the discussion.They provide very little objective evidence for anything. Anecdotal reports have only one real use. If there is a subject we have no data on they can raise a flag that something may deserve closer inspection. If on the other hand we have significant data anecdotal reports are just aberations like the 95 year old smoker. They serve no real purpose except to cause people to ignore the real data.It can and should be dismissed when there is objective evidence that the conclusion being drawn is inaccurate.That should be determined on a case by case basis, not whole scale per se.
I have no idea. I don;t know the specifics of his case. Maybe he was only on statins because his LDL was 140 and under the new guidelines he doesn't need to take them. I can't get in side his head, but as I already stated even doctors make decisions sometimes that are not supported by the evidence. This isn't about personal opinion. Its about the risk benefit analysis.Of course not and he is not the originator of this idea. All he is dong is repeating current medical theory of atherosclerosis and the mechanism by which statins most likely work. If you read my first post you would see that I said exactly the same thing in there. This is the standard medical theory of atherogenesis and rationale behind statin use today.Why did he stop taking statins?
Would you take statins or recommend them to your friends and relatives as in 3)?Yes
I would second that. I have had a heart by-pass some three years ago and 10 years before that angina. Before any treatment my cholesterol level was an unhealthy 5.7, after taking statins for 15 + years it is now a healthy 4.2 - 4.5. Garthkkwan - Would you take statins or recommend them to your friends and relatives as in 3)?macgyver -Yes
Nothing is hidden. They are telling you who sponsored the study. Its up to the reader to decide whether that may result in a conflict of interest. Asking the writer to make that decision is like asking someone accused of a crime if they are guilty. It makes no sense.We don't know if "nothing is hidden" if there is no declaration of conflict of interest. It makes no sense to say X, Y and Z (which include pharmaceutical companies with vested interests) funded the study but we are not informed in what proportions. Why should there be reluctance to disclose this information unless.......
I assume by "3)" you are referring to the current recommendation to treat people who have an LDL greater than 190? You seem to be misunderstanding things here. No one is saying that cholesterl levels aren't important. What we are saying with the new recommendations is that if someone has an average risk based on other risk factors an LDL of 190 or above is in itself enough of a risk to justify statin useThis is 3) from your post 30:
3) No risk factors but an LDL of 160 or greaterAre cholesterol levels that important?
Anecdotal stories are generally used in arguments to undermine and misdirect the discussion.They provide very little objective evidence for anything. Anecdotal reports have only one real use. If there is a subject we have no data on they can raise a flag that something may deserve closer inspection. If on the other hand we have significant data anecdotal reports are just aberations like the 95 year old smoker. They serve no real purpose except to cause people to ignore the real data.It depends on the content of the anecdotal and the context.
I have no idea. I don;t know the specifics of his case. Maybe he was only on statins because his LDL was 140 and under the new guidelines he doesn't need to take them. I can't get in side his head, but as I already stated even doctors make decisions sometimes that are not supported by the evidence. This isn't about personal opinion. Its about the risk benefit analysis.From the same article cited in my post 29 here]
When I had a routine health check-up eight years ago, my cholesterol was so high that the laboratory thought there had been a mistake. I had 9.3 millimoles of cholesterol in every litre of blood — almost twice the recommended maximum. It was quite a shock. The GP instantly prescribed statins, the cholesterol-lowering drugs that are supposed to prevent heart disease and strokes. For eight years, I faithfully popped my 20mg atorvastatin pills, without side effects. Then, one day last May, I stopped. It wasn’t a snap decision; after looking more closely at the research, I’d concluded that statins were not going to save me from a heart attack and that my cholesterol levels were all but irrelevant.Bold added by me. That is what made him stop taking statins.
YesWhat then do you make of this from the article in the BBC in my post 28?
Side-effects Prof Simon Capewell, an expert in clinical epidemiology at Liverpool University and one of the signatories, said: “The recent statin recommendations are deeply worrying, effectively condemning all middle-aged adults to lifelong medications of questionable value.Bold added by me.
I would second that. I have had a heart by-pass some three years ago and 10 years before that angina. Before any treatment my cholesterol level was an unhealthy 5.7, after taking statins for 15 + years it is now a healthy 4.2 - 4.5. GarthBecause you had those episodes, that means you have CVD and statins could be useful because of their anti-inflammatory properties and not because of their ability to keep cholesterol levels down per se. From this article here] Inflammation and Heart Disease
Cholesterol-lowering medications called statins appear to reduce arterial inflammation, but whether that’s from cholesterol reduction or something else is being debated, Bhatt said. He added that clinical trials are ongoing to see if other medications might lower inflammation in arteries and reduce the risk of heart attack and stroke. More information on the role of inflammation should be available in the next few years.
I would second that. I have had a heart by-pass some three years ago and 10 years before that angina. Before any treatment my cholesterol level was an unhealthy 5.7, after taking statins for 15 + years it is now a healthy 4.2 - 4.5. GarthBecause you had those episodes, that means you have CVD and statins could be useful because of their anti-inflammatory properties and not because of their ability to keep cholesterol levels down per se. From this article here] Inflammation and Heart Disease
Cholesterol-lowering medications called statins appear to reduce arterial inflammation, but whether that’s from cholesterol reduction or something else is being debated, Bhatt said. He added that clinical trials are ongoing to see if other medications might lower inflammation in arteries and reduce the risk of heart attack and stroke. More information on the role of inflammation should be available in the next few years.Well as well as being worried about inflammation of the present state of my arteries I am also worried about future deposits of artery blocking fat - and so am glad of a lower cholesterol level.
This is 3) from your post 30: 3) No risk factors but an LDL of 160 or greater Are cholesterol levels that important?As I have already said. Those were the old recommendations. They are NOT the current recommendations.
From the same article cited in my post 29 here When I had a routine health check-up eight years ago, my cholesterol was so high that the laboratory thought there had been a mistake. I had 9.3 millimoles of cholesterol in every litre of blood — almost twice the recommended maximum. It was quite a shock. The GP instantly prescribed statins, the cholesterol-lowering drugs that are supposed to prevent heart disease and strokes. For eight years, I faithfully popped my 20mg atorvastatin pills, without side effects. Then, one day last May, I stopped. It wasn’t a snap decision; after looking more closely at the research, I’d concluded that statins were not going to save me from a heart attack and that my cholesterol levels were all but irrelevant. Bold added by me. That is what made him stop taking statins.I can't get inside his head but even smart people make illogical decisions sometimes. Einstein once called the cosmological constant his biggest mistake only to find out later that it was actually brilliant. Thats what happens when you let your heuristics trump the data. All I can say is this doctors decision and certainly his comments are not supported by the evidence.
What then do you make of this from the article in the BBC in my post 28? Side-effects Prof Simon Capewell, an expert in clinical epidemiology at Liverpool University and one of the signatories, said: “The recent statin recommendations are deeply worrying, effectively condemning all middle-aged adults to lifelong medications of questionable value. Bold added by me.Well this one is easy. Its hyperbole and its completely wrong. There is absolutely no way in which the current recommendation would "condemn ALL middle age adults to lifelong medications". I use these recommendations every day and only a small minority of my patients qualify for treatment by the current guidelines.
Well as well as being worried about inflammation of the present state of my arteries I am also worried about future deposits of artery blocking fat - and so am glad of a lower cholesterol level.Watch this youtube video: https://www.youtube.com/watch?v=3vr-c8GeT34 Apparently, fat and cholesterol are not so bad. Sugar and simple carbohydrates are worse. Towards the end of the video, he said what blocks your arteries and it is not fat and cholesterol.
As I have already said. Those were the old recommendations. They are NOT the current recommendations.3) is part of the 2013 recommendations. Is that not current?
I can't get inside his head but even smart people make illogical decisions sometimes. Einstein once called the cosmological constant his biggest mistake only to find out later that it was actually brilliant. Thats what happens when you let your heuristics trump the data. All I can say is this doctors decision and certainly his comments are not supported by the evidence.What evidence?
Well this one is easy. Its hyperbole and its completely wrong. There is absolutely no way in which the current recommendation would "condemn ALL middle age adults to lifelong medications". I use these recommendations every day and only a small minority of my patients qualify for treatment by the current guidelines.Is this also a hyperbole? From the same BBC article:
The signatories include Royal College of Physicians president Sir Richard Thompson and former Royal College of GPs chairwoman Clare Gerada as well as cardiologists and leading academics.
Well as well as being worried about inflammation of the present state of my arteries I am also worried about future deposits of artery blocking fat - and so am glad of a lower cholesterol level.Watch this youtube video: https://www.youtube.com/watch?v=3vr-c8GeT34 Apparently, fat and cholesterol are not so bad. Sugar and simple carbohydrates are worse. Towards the end of the video, he said what blocks your arteries and it is not fat and cholesterol. I also keep off sugar and sweet things, and have done so long before my angina became chronic.
As I have already said. Those were the old recommendations. They are NOT the current recommendations.3) is part of the 2013 recommendations. Is that not current?
I can't get inside his head but even smart people make illogical decisions sometimes. Einstein once called the cosmological constant his biggest mistake only to find out later that it was actually brilliant. Thats what happens when you let your heuristics trump the data. All I can say is this doctors decision and certainly his comments are not supported by the evidence.What evidence?
Well this one is easy. Its hyperbole and its completely wrong. There is absolutely no way in which the current recommendation would "condemn ALL middle age adults to lifelong medications". I use these recommendations every day and only a small minority of my patients qualify for treatment by the current guidelines.Is this also a hyperbole? From the same BBC article:
The signatories include Royal College of Physicians president Sir Richard Thompson and former Royal College of GPs chairwoman Clare Gerada as well as cardiologists and leading academics.I can't keep repeating myself. Read my first post in this thread.
This one today, from medscape. You have to have a login with medscape to follow the link.
STATINS INCREASINGLY IMPLICATED IN CAUSING DIABETES
Largest Risk for Diabetes With Statins Yet Seen, in New Study
Liam Davenport
March 04, 2015
Statin therapy appears to increase the risk for type 2 diabetes by 46%, even after adjustment for confounding factors, a large new population-based study concludes.
This suggests a higher risk for diabetes with statins in the general population than has previously been reported, which has been in the region of a 10% to 22% increased risk, report the researchers, led by Henna Cederberg, MD, PhD, from the University of Eastern Finland and Kuopio University Hospital, and colleagues, who published their study online March 4 in Diabetologia.
(lots more on medscape)
This has been known for a while and although it’s certainly a concern there are a lot of questions. This is a population study and as such it’s difficult to correct for the obvious and not so obvious confounders such as obesity, poor diet, and inactivity which increase the probability that one would develop diabetes and also have high cholesterol (and be on a statin).
IF it turns out that the correlation is indeed a causative link it would not mean tha Statins shouldn’t be used. Given a choice between having a heart attack and getting diabetes I would prefer to have diabetes. It does mean that the equation may need to be changed but only time and more data will tell whether that needs to be done.
It’s not as simple as choosing diabetes over heart attacks, because diabetes is associated with an increased risk of a host of problems including MI’s, stroke, nephropathy, retinopathy, neuropathy, etc etc etc. Prevention would indicate efforts to remove risk factors for diabetes in order to reduce risk of all this other stuff.
It's not as simple as choosing diabetes over heart attacks, because diabetes is associated with an increased risk of a host of problems including MI's, stroke, nephropathy, retinopathy, neuropathy, etc etc etc. Prevention would indicate efforts to remove risk factors for diabetes in order to reduce risk of all this other stuff.I feel like I'm talking to a wall. Either you are not reading my posts or you are so misinformed about how MDs practice that you aren't able to accept what I have already told you but I'll say it once again. Medications are only used when lifestyle changes have failed to achieve the desired goal. Diet and exercise are ALWAYS the first tools we use but when significant time has passed and the patient is not able to achieve those goals as often happens we need to make a choice. We can either refuse to use the other available tools such as medication to help patients or we can add meds to our continued efforts at lifestyle modification. Doctors don't use meds INSTEAD of diet and exercise. They are an an adjunct to lifestyle modification. So to simplify, were I at risk and faced with the inability to control my risk with diet and exercise I would take a statin to reduce my risk of a heart attack even if it might increas my risk of developing diabetes. Heart attacks are fatal. Diabetes is just another risk factor that needs to be controlled.