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BMJ vs The Lancet: there are no winners in the ‘statins war’

BMJ vs The Lancet: there are no winners in the ‘statins war’

The editors of the BMJ and The Lancet – two heavyweight medical journals – have been arguing about statins for nearly three years. The tabloid press have dubbed the spat “statin wars”.

The gist of the debate is: should statins be offered to a wider swathe of the public? And how extensive and serious are the side effects of these cholesterol-lowering drugs?

The row kicked-off in 2013 when the BMJ published two articles claiming that the side effects from statins are much higher than clinical trials reported. In early 2014, Rory Collins, professor of medicine and epidemiology at the University of Oxford and a statin trial leader, hit back. He described the BMJ papers as flawed and misleading.

A subsequent review by an independent panel of experts found that the BMJ papers did not warrant retraction. As a response, the statin trial leaders published a review identifying the benefits of statins in the Lancet in 2016.

The latest news from the front line is that Fiona Godlee, editor of the BMJ, has written to the UK’s chief medical officer, Sally Davies, asking for an independent review of statin risks and benefits.

Unfortunately, the point of the debate is lost when reading articles in the mainstream media on this topic. Given the frequency of statin coverage in the news, it is not uncommon for people on statins to say to their GP: “I heard they’re bad, so I stopped taking them,” or “My mum took them all her life but still had a heart attack.” A recent paper in the BMJ showed that significant numbers of patients stopped taking statins as a result of the media coverage after the BMJ published the articles in 2013.

Muddying the water

Confusingly, newspaper and TV reports seem to point to statins being either entirely good or bad. They are not miracle medications, nor are they poison, yet the media continues to portray them as one or the other.

Buried in the depths of this argument between the BMJ and the Lancet, there is one truth accepted by both parties: statins have prevented heart attacks, strokes and other cardiovascular diseases. The extent to which they benefited patients, the prevalence of the side effects and the evidence for prescribing statins to wider groups of patients to benefit the health of the population is the point of this debate.

The BMJ and the Lancet both seem to argue from opposing corners, using the term “data” as a weapon. In reality, the Lancet has not published significant amounts of new data in their recently published review on statins. The BMJ editor’s calls for making the statin-trial data public and for the scrutiny of an independent review is unlikely to give a clearer picture of the incidence of side effects.

The statin trials were performed on specific groups of patients. The numbers and types of patients where statins are currently used is extrapolated from this trial evidence. There have not been clinical trials addressing every specific type of patient where statins are being used, especially in the elderly population. Relating the benefits and side effects reported from the clinical trials to the current use of statins is not likely to be accurate. So, any expensive independent review is not likely to inform us better about true statin side effects which should be the aim of any such review.

New observational studies lack the vigour of clinical trials and while they can suggest patterns and trends, are seldom conclusive. Academics debate who should receive statins based on health-economics arguments, telling us about numbers of patients who have been harmed or the number of lives that have been saved. Relating such numbers and quoting these to a patient who is having statin-related myopathy (muscle weakness) or to a patient who has had a heart attack despite taking statins is not likely to be helpful to that patient.

Perhaps more data can truly answer this question but, for this, new research is needed and funding statin studies when most statins are off-patent is difficult because there is no incentive for pharmaceutical companies to fund such studies. New studies are needed to update us about the benefits and side effects of statins with modern use but the risk of misinterpretation of the results in the media must be acknowledged. What we know is this: statins are good for most patients.