This is the cover of what’s called in the doctor biz a throw-away journal. These journals are supported by the pharmaceutical industry and are sent out free to licensed physicians. The things come in droves. Most docs glance at the covers to see if there is anything pertinent to their specific practice, maybe flip through them, glance at an article or two, then toss them in the trash. Thus the name.
Notice in this one the headlined article.
Should you put all diabetic patients on statins?
Given that this journal is supported by big pharma, see if you can predict the answer.
Once I fought through all the drug ads (38 pages in a 115 page journal) to get to the article on statins and diabetes, I found that the author, Dr. Lawrence A. Leiter of the University of Toronto, heartily recommends the use of statins in all diabetics over the age of 40.
The way this particular journal is laid out, the recommendations made by the authors of the various articles are graded from A to C as follows:
Strength of recommendation (SOR)
A Good quality patient-oriented evidence
B Inconsistent of limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
The recommendations are listed at the very start of the article so that the busy physician can read just the take-home message of the piece and have a qualitative method of assessing the strength of any particular recommendation.
The practice recommendations at the very start of this article on statins are printed in red and stand out like a sore thumb. They boldly state:
* Statins are the therapy of choice for lowering LDL cholesterol in patients with diabetes (A).
* All diabetes patients over the age of 40 should receive statin therapy, regardless of baseline LDL cholesterol (A).
So, two ‘A‘ recommendations, the strongest, most supported by the scientific evidence at hand.
The first paragraph following the bright red recommendations let’s any busy doc who only glances at the beginning know the score:
Dyslipedemia in patients with diabetes is underdiagnosed and undertreated, and diabetes patients not receiving statin therapy are at high risk for cardiovascular disease. Clinical trial data show that we should consider statins for all adults with diabetes, irrespective of cardiovascular disease status or baseline low-density lipoprotein (LDL) cholesterol levels. Furthermore, aggressive statin therapy is more beneficial than moderate treatment. Patients with diabetes typically have elevated triglycerides and low high-density lipoprotein (HDL) cholesterol levels, but their LDL cholesterol levels are similar to those in the general population. Nevertheless, emerging evidence shows that patients with diabetes may benefit from statins even in the absence of of elevated LDL. Though various agents can reduce LDL cholesterol, the most impressive cardiovascular outcomes are associated with statins.
Is it any wonder that every doctor in the world wants to put every patient on a statin?
Here we have a journal article recommending that ALL adult diabetic patients be started on statin drugs and giving this recommendation an ‘A’ rating in terms of how much scientific evidence underlies it.
If we read on down in this article we are presented with a number of studies showing us just how strong this ‘A’ evidence is. Here is what the author has to say about the Atorvastin Study for Prevention of CHD Endpoints in Non-insulin-dependent diabetes mellitus (ASPEN) which was published in Diabetes Care last year. The ASPEN study is one designed to address the very issue of statins and patients with diabetes, so it should tell us the score.
In the ASPEN [study], atorvastatin [Lipitor] 10 mg reduced the primary endpoint by 10% compared with placebo. The difference did not reach significance, perhaps due to study design, the patient population recruited, the nature of the primary endpoint, and protocol changes needed during the trial due to revised treatment guidelines [or maybe the Lipitor just doesn’t work, but this is never mentioned]; the lack of significance does not detract from the known benefits of statin therapy in diabetes patients.[my italics]
Well, that’s certainly an ‘A’ rating for strength of scientific evidence in my book.
If you read on through the rest of the studies, you find that one has a relative risk ratio of 1.37 while the rest are well below that. Since, in my opinion, the relative risk needs to be at least 2 to be meaningful, all these studies fall far short of having the scientific validity to put the 16 million adults with type II diabetes on statin drugs at a cost of $28 billion per year. Unless, of course, you’re a seller of statin drugs, then you might think differently.
Let’s see, when we look at the fine print in this article (literally, it’s the smallest print in the piece), we find that
Dr. Lawrence Leiter has received research funding from, has provided CME on behalf of, and has acted as a consultant to Astra Zeneca, Merck, Merck Schering Plough, and Pfizer. Editorial support was provided by Dr. Fiona Steinkamp of Envision Pharma Ltd. and was funded by Pfizer, inc. Dr. Leiter takes full responsibility for manuscript content.
Hmmm, let’s see now.
Pfizer makes Lipitor (a statin)
Astra Zeneca makes Crestor (a statin)
Merck makes Zocor (a statin)
Merck Schering-Plough makes Zetia (a non-statin cholesterol lowering drug)
Think Dr. Leiter might have some motivation to get a whole bunch of people on statin drugs?
Clearly, Dr. Leiter and The Journal of Family Practice are definite candidates for the Reckless award.