Lipid madness is furring up our brains
Copperfield laments the national ‘statinisation’ drive, wondering if lipid management in primary care has drifted from evidence into autopilot mode
Please don’t hate me for this. In my defence, can I point out that I see myself as One Of Us. Because I am, and have been for 30+ years. But that shouldn’t stop me calling out GP-generated bollox, should it?
Good. Because where all things cholesterol are concerned, something seems to have gone seriously wrong with our brains. I know you don’t come here for clinical hyperlipidaemia updates, but bear with me. I’d like to prove we are suffering a collective lipopsychosis, using these three examples:
- A young, fit, well and entirely cardiovascularly normal friend calls me in a panic. His practice sent him a text, asking to see him because his ‘LDL is above target at 3.2’. Which is odd: He is not on any treatment and so has no target. It seems that the practice may be systematically and mistakenly using LDL thresholds, as opposed to QRISK, when deciding on primary prevention. Which sounds technical, but only if you know f**k all about lipid management. Which leads nicely to…
- A well lady in her early 30s has been told to book an appointment to discuss going on a statin. Why? Because her TC is 6.5. Her QRISK? Thanks for asking, because the practice apparently didn’t. It’s 0.3%. This isn’t just Cholesterold School. It’s square-wheel era lipid management.
- A 40-year-old recently registered male has a legacy coded diagnosis of familial hypercholesterolaemia. Which is interesting. He has no family history. Nor any physical signs. Nor any of the diagnostic criteria whatsoever. And that’s because he hasn’t got FH. He once had a TC of 7.1, was stuck on a statin (unnecessarily), and was miscoded as FH. No harm done, apart from the unnecessary treatment, expense, anxiety and ruined insurance.
Assuming this is going on up and down the land (and I bet it is), we are unnecessarily statinising the nation.
Why? What’s happening? Are these just coding cock-ups? Are we over-automating systems? Have we delegated low-density lipoprotein interpretation to high-density staff?
Or is it the seasonal collective disorder caused by QOF-fever? After all, it’s QOF year-end and I, too, have been chasing down aberrant LDLs, literally. Which is very rewarding, in terms of points, but less so in terms of feelings pointless.
Clearly, there are many layers of dysfunction here, and none of them are attractive. The upshot is we’re being a bit rubbish. The drum bang of lipid management is deafening us to sense and logic, and the result is, in trying to save a few lives, we’re screwing a lot up. And as age inevitably renders me less One Of Us and more One Of Them, that’s a real concern.
Although, being the only person in the UK not on statin, I probably haven’t got too long to worry.
Dr Tony Copperfield is a GP in Essex
Have you got a view you want to share with Pulse?
We’re always open to first-hand pieces and opinions from GPs.
Email your piece for consideration to be published on our site.
Related Articles
READERS' COMMENTS [11]
Please note, only GPs are permitted to add comments to articles
Over prescribing of statins is only one example. Zopiclone, benzos, SSRIs, opiates, pregabalin, ADHD meds, antibiotics and NSAIDs are all dished out like smarties. We are causing enormous harm with this approach.
Loadsamoney startin statins for nowt
At the risk of statin’ (sorry 🙄) the not-so bleeding obvious, this is what happens “when a measure becomes a target, it ceases to be a good measure” (Goodhart’s Law). Cock-ups, enhancing pharma profits, or gaming the qof rewards…..this Lipid madness is definitely making us Fat-headed…
Well said, TC. I recommend readers buy Margaret McCartney’s terrific book ‘The Patient Paradox’. It emphasises in its chapter on cardiovascular risk just how little likely benefit statins are for patients who are at relatively low risk (not secondary prevention).
But we live in a risk aversion culture which makes it difficult for many GPs not to ‘play safe’.
I think we are failing shockingly to provide informed consent for these patients. We tell them they are “at risk of cardiovascular disease” and we recommend a statin. Yet we give them no information whatsoever what their ACTUAL risk is. ARR is the only thing that matters to individual patients – ie the only ones we see. I share with mine the original LIPITOR advert claiming that Lipitor reduces the risk (relative risk) of developing CVD by 36% then in the small print in the corner of the poster states ” This means in a large clinical study 3% of people taking a sugar pill or placebo had a heart attack compared to 2% taking lipitor”. What would you do?
We’ve been sued for not treating a cholesterol of 7ish in a patient who had an MI in early 50s, no family history, QRISK was very low. Big payout through NHS Resolutions. Welcome to defensive medicine.
Advisers advise, guidelines guide, the clinician decides-Something Keir Starmer and the Labour Party Have yet to grapple.
If the cost of a drug goes down to make the same profit big pharma needs to get more people on their drugs and there is no shortage of “specialist doctors and nurses “ happy to peddle an absolute risk reduction of 1 in 100 as “ best practice” and to label those who challenge as “not up to date with the guidelines “
An averagely healthy 60 year old male will have a Qrisk of around 12.
Taking statins for five years could be expected to prevent 3 or 4 “events” for every hundred men treated.
Why would you not offer treatment?
People are free to refuse, but statins have been demonstrated as ridiculously safe in large scale trials.
Why even check the cholesterol? Risk reduction is independent of cholesterol, and risk is mostly determined by other factors.
“Big Pharma” lost interest in Statins a long time ago; much more exciting drugs are available or in development. Statins have been generic for a decade or more and cost pennies.
Yes it’s popular to decry the evils of Capitalism, but the alternatives have proven far worse.
Ha, I saw (via my NHS app) that I incorrectly had a ‘familial hypercholesteraemia’ code on my record, because of a TC of 6.1 and I had to contact the practice to get this changed. I’m now (rightly) on a statin based on my 10-year CVD risk. I agree there’s a lot of confusion or sloppiness … I also speak to friends and family members worried about their ‘high’ cholesterol, but who have been given their lipid results without explanation of Q-risk and who don’t meet threshold for statins in primary prevention. Is it that Drs themselves don’t understand , or find it too hard to explain that the decision to treat is population medicine , based on costs, benefits and risks?