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Power of the press can be detrimental to drug adherence
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Statins have long been the foundation of pharmacologic management of dyslipidemia and cardiovascular disease prevention in the United States and across the world. Multiple large-scale, prospective studies have shown the benefit of statins in cardiovascular prevention. The 2013 American College of Cardiology and American Heart Association cholesterol management guidelines emphasized use of statins and expanded the number of potential patients who could be treated.
The recommendations for wider use of statins, particularly for primary prevention, have been questioned by some. There have been strong opinions expressed on both sides. However, for most, the consensus now is that for patients in whom therapy is appropriate, the benefits of statins outweigh the risks.
Treatment adherence
One of the greatest challenges of clinical practice is to persuade patients to begin and to continue statins and other medications. Statins may prevent potentially deadly CV events; however, from the perspective of a patient prescribed the medication, at best taking these drugs will cause one to feel no better and no worse, while there may be a small (but real) possibility of experiencing an adverse effect. In contrast, there is no pain or discomfort from leaving hypercholesterolemia untreated — at least not until the patient experiences the pain of an acute CV event.
As a result, many decline statin therapy when it is offered, and 20% or more may eventually discontinue, temporarily or permanently. Some stop therapy because of adverse effects or because of cost. Others are concerned about the possibility of future adverse effects, although they have not experienced an actual adverse effect themselves.
Then there are those who simply do not believe that dyslipidemia is one of the modifiable risk factors for heart disease. It is reminiscent of the controversy surrounding the measles, mumps and rubella vaccine. The science informs us that vaccinations and statins are safe and effective, yet many patients continue to be skeptical.
Too many ‘experts’
Part of the problem is that there are now an overwhelming number of sources of information and misinformation. It can be difficult for patients to know which “expert” they should trust. Finding another point of view is only a mouse click away. Many alternative medical opinions have been expressed regarding statins, dyslipidemia and heart disease, not all of which are scientific or evidence based. Some opinions are sensationalized, ignore certain information or interpret facts out of context. In the end, many patients decide to follow the advice of those who most closely align with their own personal philosophy.
In October 2013, the Australian Broadcasting Corporation (ABC) aired a two-part episode on the science television series Catalyst, titled “Heart of the Matter.” The program was critical of statins, suggesting that the benefits of therapy were exaggerated and the risks minimized. The program also questioned the relationship between dyslipidemia and CVD. It is estimated that 1.5 million Australians viewed the program.
Almost immediately, experts began criticizing the program for being misleading and for ignoring the scientific evidence. ABC was accused of frightening people away from potentially lifesaving medications. Some questioned whether patients who watched the program would stop their prescriptions, possibly resulting in a CV event or death. The episodes were subsequently removed from the ABC website after an internal review found that the program did not meet standards of impartiality.
Media’s influence
The most interesting aspect of this controversy was a follow-up study conducted after the series had aired. An analysis was done of a sample of 10% of Australian individuals who were dispensed statins through the Pharmaceutical Benefits Scheme. This analysis found what many of the critics of the Catalyst program had suspected.
After the program, there was a 28.8% increase in statin discontinuation; an estimated 28,784 Australians stopped their statin treatment. Overall, during the 8 months of the analysis, there were 504,180 fewer prescriptions of statins dispensed, estimated to have affected 60,897 people due to increased discontinuation, decreased numbers of new prescriptions being filled and/or poor adherence.
The researchers concluded that if all estimated 60,897 individuals continued to avoid statins long term, between 1,522 and 2,900 of them could go on to experience CV events, some of which could be fatal.
This analysis shows the power of the media in influencing the health care beliefs and perceptions of the public. There are often multiple sides to a story. The opportunity to express and to debate differing points of view should be encouraged. However, it is essential for journalists to take their role in influencing public opinion seriously. When a program such as Catalyst questions medical consensus, it has an obligation to provide fair balance and to objectively present both sides of the issue. If the media do not do so, there may be negative consequences.
Patient education
A story on a controversial topic certainly captures the attention of the audience. Perhaps, reviewing basic lifestyle advice and the current guidelines for CV prevention may not be quite as exciting a talking point. A diversity of opinions is expected and encouraged in social media; however, traditional media are expected to hold themselves to a higher standard, to be objective and to demonstrate fair balance. Without objectively covering all perspectives, there is the chance that a great number of people could be harmed, as the follow-up study suggests.
The scientific and medical communities must do better at informing the public about the risks and benefits of medications compared with risks of not treating. It is true that there are patients who may not yet meet treatment criteria but who are prescribed statins anyway. It also is true that adverse effects, although not as common as many believe they are, can and do happen. However, these two issues must not distract from the fact that there are many patients at increased CV risk who are not being treated and who go on to experience CV events. Too often, fear about medications completely outweighs concerns about the risks of dying prematurely. We must do better.
- References:
- Abramson JD, et al. BMJ. 2013;doi:10.1136/bmj.f6123.
- Australian Broadcasting Corporation. Catalyst. Heart of the Matter. Sydney: ABC, 2014. http://www.abc.net.au/catalyst/heartofthematter. Accessed July 15, 2015
- Australian Broadcasting Corporation. Media Watch: Episode 41: Nov. 11, 2013 http://www.abc.net.au/mediawatch/transcripts/s3888657.htm and http://www.abc.net.au/mediawatch/transcripts/1341_heartfoundation2.pdf. Accessed July 15, 2015.
- Ellis JJ, et al. J Gen Intern Med. 2004;19:638-645.
- Pencina MJ, et al. N Engl J Med. 2014;doi:10.1056/NEJMoa1315665.
- Robinson JG. JAMA. 2013;doi:10.1001/jama.2013.281355.
- Schaffer AL, et al. Med J Aust. 2015;202:591-594.
- Stone NJ, et al. Circulation. 2014;doi:10.1161/01.cir.0000437738.63853.7a.
- Taylor FC, et al. JAMA. 2013;doi:10.1001/jama.2013.281348.
- For more information:
- Thomas Repas, DO, FACP, FACOI, FNLA, FACE, CDE, is an endocrinologist, lipidologist, physician nutrition specialist and certified diabetes educator in clinical practice at the Regional Medical Clinic Endocrinology and Diabetes Education Center in Rapid City, SD. He reports financial relationships with Amgen, Bristol-Myers Squibb, Hanmi Pharmaceuticals, Janssen Pharmaceuticals, Merck, Novo Nordisk, Sanofi Aventis and Trial-net.