Statins are the most commonly prescribed, and perhaps one of the most controversial, drugs in the UK. In 2018, 7.9 million people took them, and 71 million statin prescriptions were dispensed (Nuffield Department of Population Health, 2021).
A recently published study evaluated incident cardiovascular disease (CVD) and the initiation, as well as subsequent adherence to, statin treatment for the treatment of primary prevention in those who have just been diagnosed with high cholesterol.
In 2018, 7.9 million people in the UK took statins, and 71 million statin prescriptions for statins were dispensed
Ryou et al (2021) carried out a population-based retrospective cohort study using the National Health Insurance Service-Health Screening Cohort (NHIS-HEALS) from the Republic of Korea. Therefore, a limitation of this study may relate to the generalisability of this study to other populations. Nonetheless, the study was large, including 11 320 people with no previous history of CVD incidence, all between 40 and 79 years of age. All participants had an elevated total cholesterol level (more than 240 mg/dl) and had started statin treatment within 24 months of the national health screening from 2004 to 2012 identified in the NHIS-HEALS. The primary outcome, CVD, was defined as first-ever admission or death due to ischaemic heart disease, acute myocardial infarction (MI), revascularisation or stroke. Ryou et al (2021) found that early statin initiation significantly lowered the risk of CVD outcomes when compared with starting the treatment late. Of those who started the treatment early, statin discontinuers were observed to have a significantly higher risk for CVD in comparison with persistent users, while statin re-initiators had an attenuated risk increase. The authors concluded that, in statin users with newly diagnosed hypercholesterolaemia, early statin initiation is associated with lower CVD risk compared with late initiation. Further, statin discontinuation is associated with an increased risk of CVD, but re-initiation attenuated the risk.
In 2016, a British Heart Foundation (BHF)-funded study found that patients were 11% and 12% more likely to stop taking statins for primary and secondary prevention, respectively, following a period in which statins received extensive negative media coverage (Matthews et al, 2016). The BHF (2021) also pointed to a Danish study published in 2015 which found that every negative nationwide news story meant that people were 9% more likely to stop taking statins, which then led to a 26% greater risk of MI and an 18% increase in the risk of cardiovascular mortality in those who stopped taking the medication (Nielsen and Nordestgaard, 2016).
Patients may also feel reassured of the safety of statins as a result of pointing out that NHS England (2019) is considering making them available over the counter at high dosage, so no prescription is required. Already low-dose statins are available over the counter (BHF, 2021). In the NHS Long Term Plan, the NHS has set out the desire to prevent 150 000 MIs and strokes, and making high-dose statins accessible over the counter could be one way of tackling this (NHS England, 2019). Therefore, it may be safer to make these drugs more readily available without prescription but, instead, with a discussion with the pharmacist, so that patient uptake may be higher, particularly among groups of people who do not routinely visit their GP.
According to NHS England (2019), up to two-thirds of people at high risk of MI and stroke do not take statins but could benefit from doing so. Therefore, the BHF (2021) recommended expressing the potential benefit, not just in relative terms, but also in terms of absolute reduction in 5-year risk. The risk of major cardiovascular events is reduced by around 25% for each micromole per litre reduction in low-density lipoprotein (LDL) after taking statins, according to one review (Collins et al, 2016). In other words, lowering the LDL cholesterol of 10 000 patients by 2 mmol/litre over 5 years ‘would typically prevent major vascular events from occurring in about 1000 patients’ (Collins et al, 2016). This means that 10% of people treated would benefit, representing an ‘absolute benefit’ of 10%. For people taking statins for secondary prevention, the absolute benefit is around 5% (BHF, 2021). However, this is not always easy for patients to understand, and counselling about prescribing such a medication can be tailored to the individual.