Denial is not just for climate-change anymore. In a political environment in which charges of puffery, deception and fake news abound, a new controversy has been joined, and it returns to grounds that have long proved fertile for conspiracy theories: medicine.
The newest charge of "fake news" has been lodged against those who would argue that statin medications cause more harm than good, and that fad diets, natural remedies and wishful thinking will protect you better from heart disease than these ubiquitous prescription drugs.
They are everywhere on the Internet, says Cleveland Clinic cardiologist Dr. Steven Nissen. Type the term "statin risks" into a search engine, and you'll get about 3.5 million hits. Those overwhelmingly lodge misleading charges against statins and hawk some alternative whose effectiveness has not been demonstrated by science, says Nissen.
Nissen says he was incredulous to find that some online sites suggest that patients with higher levels of LDL cholesterol (the kind that cardiologists call "bad cholesterol") are healthier. Perhaps, he said, they were taking their cue from climate-change deniers who sing the praises of more carbon dioxide in the atmosphere.
Type in "statin benefits," by contrast, and you'll get a skimpier 655,000 results, Nissen reported.
"Statins have developed a bad reputation with the public, a phenomenon driven largely by proliferation on the Internet of bizarre and unscientific but seemingly persuasive criticism of these drugs," Nissen wrote in an editorial published Monday in the Annals of Internal Medicine.
"We are losing the battle for the hearts and minds of our patients to websites developed by people with little or no scientific expertise, who often peddle 'natural' or 'drug-free' remedies for elevated cholesterol levels," adds Nissen. This "Internet-driven cult" denies statins' benefits and whips up fears of side effects, then profits from the resulting confusion by peddling snake oil.
Nissen's incendiary remarks come against the backdrop of what had seemed mostly settled science: that statin medications can — and have — cut rates of heart attack and stroke when they're taken by people who need them.
But this consensus of cardiologists has hardly prompted a nation of devotees, leaving experts like Nissen to wonder why statins have not been more widely embraced, and why they are abandoned by so many.
Of the 56 million Americans who are considered candidates for drugs with names like simvastatin, lovastatin, pravastatin and atorvastatin, just about half that number take them. And among those who get a statin prescription from a doctor — even among patients who've had a heart attack or stroke and would dramatically reduce their odds of having another — the rate at which statin medications are abandoned falls between 40 and 60%.
For a nation that loses almost a billion dollars a day to heart attacks and strokes, the opportunity costs of such statin-refusal are high. But steep costs are also incurred by patients who abandon a statin regimen prescribed by the doctor, or refuse to consider taking the medications when they're indicated.
In 19 separate studies, researchers have found that patients who discontinue a statin medication are anywhere from 22% to five times likelier than those who stay on statins to develop cardiovascular disease.Those same studies have placed statin-abandoners's odds of dying prematurely somewhere between 25% higher and 2½ times higher than those of patients who stayed on statins.
Nissen's editorial charges comments came in response to yet another study showing that patients abandoning a statin prescription are running a significant risk — though one more modest than past research suggests.
The new research, also published Monday in the Annals of Internal Medicine, draws on the medical records of more than 28,000 patients at Beth Israel Hospital in Boston who got a statin medication and registered a complaint with their doctor about an unpleasant side effect. It compared the outcomes over four years of the roughly 70% of complainers who continued on one statin to those of the 30% who did not.
The new study found that those patients who quit taking their statin medication were 14% more likely than patients who stayed on their medication to suffer a heart attack or stroke or die from such a cardiovascular event. It suggests that for every 59 patients who stop statin therapy, one would incur a stroke, heart attack or death over the next four years. And one additional statin-abandoner would die for every 83 who stop taking the medication.
But researchers are more divided over why people abandon statins. Their debate turns on the relative impact of real side effects, and the magnifying effects of patients' expectations, which are often fomented by dramatic online accounts.
As many as 20% of patients who are prescribed a statin medication to lower their cholesterol complain of side effects such as muscle pain and weakness, stomach upset or forgetfulness.
For many, the muscular and stomach problems are very real. But, as difficult as it is for doctors to tell us, there's growing evidence that sometimes, those side effects have been induced by suggestion.
This is the inverse of the placebo effect — often called the "nocebo effect" — and researchers in recent years have been engaged in a heated debate over how common statins' side effects truly are.
In one clinical trial, in which researchers warn of possible side effects like muscle aches, 10% of subjects who got a statin complained of muscle aches. But 5% of those who got a placebo treatment did. In a widely cited study that Nissen helped conduct, the rate of "nocebo-induced" side effects was far higher.
Given the mind's power over the body, the suggestion of a possible side effect can make it so.
"We now are a generation of people who go to Twitter and Facebook and the Internet for medical information, and there is this largely cultlike opposition to these drugs out there," said Nissen. "These alternative facts that are out there, and they seem like truth to many people."
Dr. Paul D. Thompson, chief of cardiology at Hartford Hospital and professor of Medicine at University of Connecticut, has long warned that side effects — real side effects — are a problem with statins that must be addressed. He thinks Dr. Nissen may be playing the provocateur with his inflammatory charges.
Nissen's got a point, says Thompson, who was not involved in research published Monday. But doctors cannot easily dismiss their patients' complaints, he adds.
"No, I don't think it's entirely an Internet conspiracy. I do think there's a lot of poorly documented information on the Internet that confuses people," said Thompson. "But that is partly our fault: A patient will take mediations if they trust their doctor and think their doctor is doing the best for them."
As for dealing with side effects, Thompson cautions that "it doesn't do any good in my experience to tell people they're full of it or they're nutty."
Physicians need to acknowledge their patients' concerns and stop the medicine to see if symptoms go away, says Thompson. And then they need to try again, either with a lower dose or a different statin medication, and make the case that staying on a statin can make a big difference for the patient, Thompson added.
Nissen, too, says he tries hard to convince patients who need them to stick with statins.
"We have to trust patients with scientific facts and speak about the science." He'll discuss what research has shown, tell them about the "nocebo effect," and often send them home with some reading. But in the end, he won't mince words about the dangers they are running if they quit, he adds.
Physicians, Nissen wrote, "must take the time to explain to our patients that discontinuing statin treatment may be a life-threatening mistake. Passive acceptance of harmful pseudoscience is not an option."
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