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19 July 2004
Amid the controversy over the most effective way to prevent heart attacks with cholesterol-lowering drugs (statins), Professor James Shepherd from University Department of Pathological biochemistry at Glasgow Royal Infirmary says, Over-the-counter statins are the only way to go for doctors restrained by budgets and will change the face of preventative cardiology.
Speaking at Bioscience 2004 on Monday 19 July, Professor Shepherd said that the introduction of statins in the 1980s provided the first really effective tool for lowering cholesterol and silenced the critics of cholesterol management as a means of reducing the risk of heart attack
Providing statins to all those who could benefit from them is, inevitably, costly. Heart disease is Britains biggest killer and every year, 270,000 people in the UK have a heart attack. The highest rates of death are in Scotland. Statins could reduce the risk of heart attack by one third but this would mean treating one quarter of the population. The National Health Service are stretched to meet the total £700 million UK bill for statins for the six percent of patients at highest risk.
The implication is that if we limit statins prescription to those at highest risk, others who are at moderate risk of a heart attack wont get them, said Professor Shepherd.
This year, the UK will be the first country in the world to make simvastatin, the most widely used cholesterol-lowering drug, available without a prescription. Professor Shepherd urges pharmacist to carry out health checks to determine a persons level of risk, taking account factors such as smoking, obesity and high blood pressure, before selling statins. Those at high risk would be referred to their GP.
However, many cardiologists are worried that although the side effects of high doses of statins are documented, there are no trials of over-the-counter statins for primary prevention of heart disease. Enabling people to buy statins directly from their local pharmacists could create a divide between those who can afford them and those who cannot; those who are overly concerned and those who deny their possible risk.
But of course, no clinical trial can truly reflect the multi-faceted biology of real life and to eliminate a disease caused by the insidious accumulation of cholesterol over a life time would require very long trials, said Professor Shepherd.
In addition to a persons lifestyle, not everyone responds well to statin treatment. Nature is not as easily tamed as we might hope, he said. The recent discovery of a drug called ezetimibe appears to be a very effective alternative for people at high risk of a heart attack but whose cholesterol is not adequately lowered by statins.
Statins work by preventing the body making cholesterol, whereas ezetimibe blocks cholesterol absorption. Combining the two therapies takes us into the realm of cholesterol lowering capability that we could not have dreamt of a decade ago, he says.
Studies have already shown that inhibiting both cholesterol production and absorption can be achieved with a combination of ezetimibe and the lowest dose of statins and, now, possibly ezetimibe as part of a long-term treatment strategy.
Professor Shepherd however cautions that making statins available without a prescription is not a cure in itself fro heart disease. It is till just as important for people not to smoke, take regular exercise, keep their weight in check and cut don on fatty foods.
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