The 2013 cholesterol guideline controversy: Would better evidence prevent pharmaceuticalization?

Which LDL Value Should Clinicians Look at?

Objectives  LDL cholesterol is routinely estimated by the Friedewald formula to guide the treatment of dyslipidemia. However, Friedewald equation has certain limitations, especially with high triglyceride levels. Direct methods are available for LDL estimation but have received relatively little scrutiny in the Indian setting. This study was aimed at comparing the calculative and direct methods of LDL estimation in Indian hyperlipidemic patients. Materials and Methods  In this observational study, data from 380 consecutive lipid profiles of patients visiting a tertiary care hospital in Mumbai were analyzed retrospectively. CHOD PAP method was used to estimate total cholesterol. Enzymatic colorimetric method was used to estimate triglycerides. Enzyme selective protection method was used to estimate HDL. Direct LDL was estimated by homogenous enzymatic colorimetric assay and very low-density lipoprotein was calculated, whereas Friedewald's formula was used to derive calculated LDL. Results  Total cholesterol values correlated positively with the LDL values measured by both methods. However, a statistically significant difference was noted between the correlation coefficients of both the methods. Triglyceride values correlated weakly with the LDL levels measured by both the methods. A weak negative correlation was observed with LDL by the calculated method, whereas a weak positive correlation existed between TG and LDL by the direct method. The difference between the correlation coefficients was statistically significant. Conclusion  Both direct and calculated methods of LDL estimation have their limitations. A robust study with a larger sample size is needed to further investigate whether the differences in the different LDL estimation methods can translate to "clinical relevance" in the Indian setting.

Are Corporations Re-Defining Illness and Health? The Diabetes Epidemic, Goal Numbers, and Blockbuster Drugs

While pharmaceutical industry involvement in producing, interpreting, and regulating medical knowledge and practice is widely accepted and believed to promote medical innovation, industry-favouring biases may result in prioritizing corporate profit above public health. Using diabetes as our example, we review successive changes over forty years in screening, diagnosis, and treatment guidelines for type 2 diabetes and prediabetes, which have dramatically expanded the population prescribed diabetes drugs, generating a billion-dollar market. We argue that these guideline recommendations have emerged under pervasive industry influence and persisted, despite weak evidence for their health benefits and indications of serious adverse effects associated with many of the drugs they recommend. We consider pharmaceutical industry conflicts of interest in some of the research and publications supporting these revisions, and in related standard-setting committees and oversight panels. We raise concern over the long-term impact of these multifaceted involvements. Rather than accept industry conflicts of interest as normal, needing only to be monitored and managed, we suggest challenging that normalcy, and ask: what are the real costs of tolerating such industry participation? We urge the development of a broader focus to fully understand and curtail the systemic nature of industry's influence over medical knowledge and practice.

Analysis of conflicts of interest among authors and researchers of European clinical guidelines in cardiovascular medicine

OBJECTIVES

We aimed to assess the frequency and nature of financial conflicts of interest among both the guideline committee authors and the authors of research studies used to support the European Society of Cardiology (ESC) guidelines.

DESIGN

We evaluated the competing interests of the doctors that write five of the key ESC clinical practice guidelines (CPG): valvular heart disease (VHD), atrial fibrillation (AF), pericardial diseases (PD), heart failure (HF) and myocardial revascularisation (IHD). In addition, we examined the funding sources of studies cited in the recommendations that were related to pharmaceutical agents. If a study was sponsored by industry, the disclosures of all authors were reviewed to assess whether there was a financial conflict of interest with the study funder.

RESULTS

In total, there were 603 recommendations (PD 112, VHD 111, HF 169, IHD 97 and AF 114) across the five guidelines, of which, 271 (45% (PD 26, VHD 23, HF 72, IHD 84 and AF 66)) related to pharmaceutical agents. At least 80% of guideline committee authors, except for the PD guidelines, had a relevant financial conflict of interest, with the most frequent being a direct personal payment (68-82%). Industry support for studies varied across the guidelines from 5% (PD) to 65% (IHD). If a study was funded by industry, authors were frequently (55-90%) conflicted with the industry sponsor.

CONCLUSIONS

The majority of the doctors that write clinical guidelines have a relevant financial conflict of interest. In addition, industry sponsorship of studies is frequent, and authors are often conflicted with the study funder. We propose that physicians that write clinical guidelines should be free of such financial conflicts of interest to maintain scientific integrity and independence in the clinical guidelines.

A qualitative exploration of the prescribing and use of statins in asymptomatic people in Ireland: A case of medicalisation, biomedicalisation and pharmaceuticalisation

There has been a notable increase in the use of statins in people without cardiovascular disease but who may be at risk in the future. The majority of statin users now fall into this category but little research has focused exclusively on this group. Debate has ensued regarding medicating asymptomatic people, and processes described variously as medicalisation, biomedicalisation and pharmaceuticalisation are used to explain how this happens. These overlapping and interrelated processes require issues to be 'problemised' as medical problems requiring medical solutions given the prevailing understandings of health, risk and disease. However, current understandings of risk and disease are not simply the result of technological and scientific advances, they are also socially constructed. We interviewed members of the public, GPs and others, and found that rather than high cholesterol being seen as one of several risk factors that contributes to heart disease, it tended to be promoted simplistically to the status of a disease needing treatment of itself. Statins were justified by those taking them as different to 'unnecessary medicines'. However, some participants demonstrated resistance to statins, worried about over-medicalisation and deviated from accepted practices, indicating a complex 'muddling through' in the face of uncertainty.

Statins for primary prevention of cardiovascular disease: modelling guidelines and patient preferences based on an Irish cohort

BACKGROUND

Changes in clinical guidelines for primary prevention of cardiovascular disease (CVD) have widened eligibility for statin therapy.

AIM

To illustrate the potential impacts of changes in clinical guidelines.

DESIGN AND SETTING

Modelling the impacts of seven consecutive European guidelines based on a cohort of people aged ≥50 years from the Irish Longitudinal Study on Ageing.

METHOD

The eligibility for statin therapy of a sample of people without a history of CVD was established, according to changing guideline recommendations and modelled associated potential costs. The authors calculated the numbers needed to treat (NNT) to prevent one major vascular event in patients at the lowest baseline risk for which each of the seven guidelines recommended treatment, and for those at low, medium, high, and very-high risk according to 2016 guidelines. These were compared with the NNT that patients reported as required to justify taking a daily medicine.

RESULTS

The proportion of patients eligible for statins increased from approximately 8% in 1987 to 61% in 2016; associated costs rose from €13.9 million to €107.1 million per annum. The NNT for those at the lowest risk for which each guideline recommended treatment rose from 40 to 400. By 2016, the NNT for low-risk patients was 400 compared to ≤25 very-high risk patients. The proportion of patients eligible for statins achieving NNT levels that patients regarded as justified to taking a daily medicine fell as guidelines changed over time.

CONCLUSION

Increased eligibility for statin therapy impacts large proportions of the present population and healthcare budgets. Decisions to take and reimburse statins should be considered on the basis of expected cost-effectiveness and acceptability to patients.

Statins for the primary prevention of cardiovascular disease: an overview of systematic reviews

OBJECTIVE

To synthesise evidence from exclusively primary prevention data on the effectiveness of statins for prevention of cardiovascular disease (CVD), including stroke, and outcomes stratified by baseline risk and gender.

DESIGN

Overview of systematic reviews (SRs) using Revised-AMSTAR approach to assess quality.

DATA SOURCES

Cochrane Database of Systematic Reviews, MEDLINE, Embase, PubMed, Scopus and PROSPERO to June 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

SRs of randomised control trials (RCTs) or individual patient data (IPD) from RCTs, examining the effectiveness of statins versus placebo or no treatment on all-cause mortality, coronary heart disease, CVD (including stroke) and composite endpoints, with stratification by baseline risk and gender.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed methodological quality. A narrative synthesis was conducted.

RESULTS

Three SRs were included. Quality of included SRs was mixed, and none reported on the risk of bias of included trials.We found trends towards reduced all-cause mortality in all SRs (RR 0.91 [95% CI 0.85 to 0.97]), (RR 0.91 [95% CI 0.83 to 1.01]) and (RR 0.78 [95% CI 0.53 to 1.15]) though it was not statistically significant in two SRs. When stratified by baseline risk, the effect on all-cause mortality was no longer statistically significant except in one medium risk category. One review reported significant reductions (RR 0.85 [95% CI 0.77 to 0.95]) in vascular deaths and non-significant reductions in non-vascular deaths (RR 0.97 [95% CI 0.88 to 1.07]). There were significant reductions in composite outcomes overall, but mixed results were reported in these when stratified by baseline risk. These reviews included studies with participants considered risk equivalent to those with established CVD.

CONCLUSIONS

There is limited evidence on the effectiveness of statins for primary prevention with mixed findings from studies including participants with widely ranging baseline risks. Decision making for the use of statins should consider individual baseline risk, absolute risk reduction and whether risk reduction justifies potential harms and taking a daily medicine for life.

TRIAL REGISTRATION NUMBER

CRD42017064761.