Statins

[Ivor the Engineer]

I take it from reading that report that you will also be advocating that if people don't change their lifestyle by moving up the socio-economic ladder they also shouldn't be given statins..... ?

I don't know where you've got that idea from

Are you saying there is no way for an individual that is classed in a lower socio-economic group to reduce their risk of CVD without either (a) taking statins or (b) getting richer and/or more posh?

Next you'll be saying smoking is one of the few pleasures they have in life...

BTW, if they can afford to buy cigarettes they can afford to buy statins too.

 

[Darat]

I don't know where you've got that idea from

Are you saying there is no way for an individual that is classed in a lower socio-economic group to reduce their risk of CVD without either (a) taking statins or (b) getting richer and/or more posh?

Next you'll be saying smoking is one of the few pleasures they have in life...

BTW, if they can afford to buy cigarettes they can afford to buy statins too.

No what I am saying is that being of a lower social-economic group increases your risk so applying your reasoning you would have to say to the patient "you have an increased risk of cardiovascular disease because you are in a 'lower' socio-economic group, unless you make lifestyle changes to change your group we won't prescribe you with statins".

It is exactly the same as saying:

"you have an increased risk of cardiovascular disease because you are overweight, unless you make lifestyle changes to change your weight we won't prescribe you with statins".

 

[Michael Redman]

Do statins increase the cost to the health service by letting people who would have died in their 50's of a heart attack...

Preventing people from dropping dead at the height of their economic productivity is probably worth the additional cost. Economically, you're best off keeping people as healthy as possible as long as possible.

The idea that people who are overweight should simply get in better shape instead of taking statins presents an unrealistic false choice. If the only reason to keep from giving people statins is to inspire them to get in shape out of fear of death, I don't think that's a very good reason. People who need statins should take statins. People who need to lose weight should lose weight. Separate issues.

(I do agree, though, that it might be beneficial to find a way to charge people for lifestyle choices that put a larger burden on the public and/or reward people who are less risky. Nothing motivates like the pocketbook.)

 

[Ivor the Engineer]

Isn’t this really the “abstention-only” argument, with the target changed from “horny teenagers” to “fat slobs?” After all, if you give the kids condoms they’re only going to use them, but if you don’t, they’ll all be models of purity who arrive at their wedding nights unsullied and completely free of babies and diseases.

That's an interesting point. In the UK we have a problem with teenage pregnancies and STD's are on the rise, even though condoms have probably never been more available. What has changed is the belief that these are things that will screw up your life in some way. E.g., HIV is not seen as a death sentence any more.

It might be a nice theory, but this here is the real world where some people can’t or won’t or don’t know how to lose weight. This is the world where people are fat because they have low literacy and little access to health information, or because the traditional food of their homeland is laden with excess calories, or because they have to work two jobs and literally have no time for exercise, or maybe because they’re depressed and use food as a comfort item but don’t feel up to exercising.

No study has ever successfully shown a four-year maintenance of weight loss. Certainly, it’s happened outside of studies, so it’s possible, but it’s not that simple.

I agree the root causes are hard to tackle and probably cost more in the medium to long term to solve. But I see the alternative (most of the adult population being medicated) as even worse.

 

[Ivor the Engineer]

No what I am saying is that being of a lower social-economic group increases your risk so applying your reasoning you would have to say to the patient "you have an increased risk of cardiovascular disease because you are in a 'lower' socio-economic group, unless you make lifestyle changes to change your group we won't prescribe you with statins".

It is exactly the same as saying:

"you have an increased risk of cardiovascular disease because you are overweight, unless you make lifestyle changes to change your weight we won't prescribe you with statins".

You mean like being black makes you more likely to be of low IQ?

That's why they're called individual risk factors.

 

[Ivor the Engineer]

Preventing people from dropping dead at the height of their economic productivity is probably worth the additional cost. Economically, you're best off keeping people as healthy as possible as long as possible.

The idea that people who are overweight should simply get in better shape instead of taking statins presents an unrealistic false choice. If the only reason to keep from giving people statins is to inspire them to get in shape out of fear of death, I don't think that's a very good reason. People who need statins should take statins. People who need to lose weight should lose weight. Separate issues.

(I do agree, though, that it might be beneficial to find a way to charge people for lifestyle choices that put a larger burden on the public and/or reward people who are less risky. Nothing motivates like the pocketbook.)

I don't think they are separate issues. People often have high cholesterol (and immediate health problems) because they have poor diet, little exercise and are overweight or obese. If they are smoking as well, isn't it rather futile treating them for high cholesterol? I wonder how much the problems caused by obesity and smoking, excluding CVD, cost the economy and health service?

 

[Michael Redman]

I don't think they are separate issues. People often have high cholesterol (and immediate health problems) because they have poor diet, little exercise and are overweight or obese. If they are smoking as well, isn't it rather futile treating them for high cholesterol?

Only if you make the assumption that the benefits of statins do not accrue in people who have those other risk factors. If that were true (which seems unlikely), then you would be correct, it would be pointless to give statins to those people. But if you are incorrect, then, indeed, they are separate issues.

I wonder how much the problems caused by obesity and smoking, excluding CVD, cost the economy and health service?

Although they do suggest other areas in need of attention, those costs are irrelevant to the decision of whether to give people statins when the drugs are indicated. The only question that matters there is whether the cost of giving them statins will be recouped on lowered healthcare dollars and increased worker productivity.

 

[Ivor the Engineer]

Only if you make the assumption that the benefits of statins do not accrue in people who have those other risk factors. If that were true (which seems unlikely), then you would be correct, it would be pointless to give statins to those people. But if you are incorrect, then, indeed, they are separate issues.

Although they do suggest other areas in need of attention, those costs are irrelevant to the decision of whether to give people statins when the drugs are indicated. The only question that matters there is whether the cost of giving them statins will be recouped on lowered healthcare dollars and increased worker productivity.

There has been a recent article in the Lancet that indicated that statins do not significantly alter when a person dies, only what they die of.

Your point is valid, if the cost of the statins is recouped in income tax, national insurance payments and savings for the health service by avoiding more expensive treatment related to CVD, then they probably pay for themselves, possibly many times over. I'm not sure they do though. Adding up all the costs for treatment of cancer, diabetes, hip and other joint replacements, etc. that unhealthy people are going to need, do they really reduce expenditure on healthcare?

 

[Darat]

You mean like being black makes you more likely to be of low IQ?

No idea, since I don't know if that is true or not (although I suspect it isn't).

That's why they're called individual risk factors.

And for most individuals being of "lower" socio-economic group increases their individual risk factors of developing cardiovascular-vascular disease just like for most individuals being overweight increases their individual risk factors. Sorry Ivor but your reasoning regarding this issue is just all over the place, it's not consistent (and doesn't seem to be based on any evidence).

Your reasoning boils down to "we won't provide an effective medication to you because you don't live an approved lifestyle".

 

[Darat]

There has been a recent article in the Lancet that indicated that statins do not significantly alter when a person dies, only what they die of.

Your point is valid, if the cost of the statins is recouped in income tax, national insurance payments and savings for the health service by avoiding more expensive treatment related to CVD, then they probably pay for themselves, possibly many times over. I'm not sure they do though. Adding up all the costs for treatment of cancer, diabetes, hip and other joint replacements, etc. that unhealthy people are going to need, do they really reduce expenditure on healthcare?

There is a contradiction in what you are putting forward - if statins do not alter significantly when you will die than there will be no additional costs for treatments that people will need because they are living longer so we can ignore that.

Your point that "unhealthy" people will need additional treatments because of their general state of health is not an argument against prescribing statins to people who don't live the lifestyle you deem "acceptable", it is an argument for saying we should encourage people to live in a way that we know will result in a general better state of health.

 

[Ivor the Engineer]

<snip>

Your reasoning boils down to "we won't provide an effective medication to you because you don't live an approved lifestyle".

My reasoning boils down to if you are choosing to behave in a way that increases your risk of CVD, you should pay for the risk reduction of CVD provided by statins. For example, the NHS could charge cost price or above to those who choose to take statins as opposed to alter their behaviour, just as the government puts tax on cigarettes.

 

[Ivor the Engineer]

There is a contradiction in what you are putting forward - if statins do not alter significantly when you will die than there will be no additional costs for treatments that people will need because they are living longer so we can ignore that.

That assumes that what they end up dying of costs the same or less than treating CVD.

Your point that "unhealthy" people will need additional treatments because of their general state of health is not an argument against prescribing statins to people who don't live the lifestyle you deem "acceptable", it is an argument for saying we should encourage people to live in a way that we know will result in a general better state of health.

Making people pay for their quick-fix drugs encourages them to live in a way that we know will result in a general better state of health.

 

[Darat]

My reasoning boils down to if you are choosing to behave in a way that increases your risk of CVD, you should pay for the risk reduction of CVD provided by statins. For example, the NHS could charge cost price or above to those who choose to take statins as opposed to alter their behaviour, just as the government puts tax on cigarettes.

Which is exactly the reasoning I posted above - the problem is that you are not consistent with using this reasoning in deciding who should qualify for "free" health-care.

 

[Ivor the Engineer]

Which is exactly the reasoning I posted above - the problem is that you are not consistent with using this reasoning in deciding who should qualify for "free" health-care.

Please point out my inconsistencies and I will correct them.

 

[Darat]

That assumes that what they end up dying of costs the same or less than treating CVD.

Er no it doesn't, if statins don't increase lifespan whether they have them or not they will live the same amount of time and therefore will require the same treatments. Only if statins significantly increase lifespan would there be additional costs incurred by the NHS.

Making people pay for their quick-fix drugs encourages them to live in a way that we know will result in a general better state of health.

Any evidence to support this?

 

[Darat]

Please point out my inconsistencies and I will correct them.

Ivor - I have already done so several time (and others have as well) for some reason you don't seem to see your inconsistent application of your reasoning over this issue.

I'll try again - there are whole range of factors that mean some people are more likely to develop CVD, many of these factors are "choices" people make however you only seem to use the fact that people make these choices in certain areas.

This means that you would provide all the treatment someone overweight requires after they have had a stroke but you won't provide treatment for them before they have a stroke because they are overweight and that is their "choice".

Yet you won't apply the same reason to people in a "lower" social-economic grouping despite the fact we know that increases their individual risk of developing CVD (regardless of other risk factors such as being overweight).

This is just not consistent. Now don't get me wrong I don't expect perfect consistency from first principles when we are discussing real-world situations but (so far) the reason you have produced for not giving treatment to people that you have decided have a "bad" lifestyle seems to be based on nothing more than to be blunt "fat people can choose not to be fat and if they choose to be fat - tough".

 

[Ivor the Engineer]

Er no it doesn't, if statins don't increase lifespan whether they have them or not they will live the same amount of time and therefore will require the same treatments. Only if statins significantly increase lifespan would there be additional costs incurred by the NHS.

That is incorrect. For example, if person not on statins has a non-fatal heart attack at 50, lives 10 more years, during which time they are less mobile so avoid the need for a hip replacement. A person on statins puts the heart attack off until 60, is more mobile and needs a hip replacement at 55.

Any evidence to support this?

That if you offer treatment for what is the better long-term solution (weight loss, diet changes, stop smoking) for less than the short-term quick-fix (statins), that you will get more people taking up the better long-term solution?

I'll try to find some for you, but positive and negative financial incentives are used all over the place to influence our behaviour.

 

[Darat]

That is incorrect. For example, if person not on statins has a non-fatal heart attack at 50, lives 10 more years, during which time they are less mobile so avoid the need for a hip replacement. A person on statins puts the heart attack off until 60, is more mobile and needs a hip replacement at 55.

Lifetime costs are the same for both scenarios (adjusted for inflation).

That if you offer treatment for what is the better long-term solution (weight loss, diet changes, stop smoking) for less than the short-term quick-fix (statins), that you will get more people taking up the better long-term solution?

I'll try to find some for you, but positive and negative financial incentives are used all over the place to influence our behaviour.

I don't disagree they are used but you need to show that your balance would be effective in this scenario.

 

[Ivor the Engineer]

Ivor - I have already done so several time (and others have as well) for some reason you don't seem to see your inconsistent application of your reasoning over this issue.

I'll try again - there are whole range of factors that mean some people are more likely to develop CVD, many of these factors are "choices" people make however you only seem to use the fact that people make these choices in certain areas.

This means that you would provide all the treatment someone overweight requires after they have had a stroke but you won't provide treatment for them before they have a stroke because they are overweight and that is their "choice".

Yet you won't apply the same reason to people in a "lower" social-economic grouping despite the fact we know that increases their individual risk of developing CVD (regardless of other risk factors such as being overweight).

This is just not consistent. Now don't get me wrong I don't expect perfect consistency from first principles when we are discussing real-world situations but (so far) the reason you have produced for not giving treatment to people that you have decided have a "bad" lifestyle seems to be based on nothing more than to be blunt "fat people can choose not to be fat and if they choose to be fat - tough".

Overweight and obese people should be treated for their weight problem, not given medication to mitigate the risks of staying overweight or obese. The same goes for all unhealthy behaviours within the control of the individual.

Does being in a lower socio-economic group increase their individual risk of developing CVD, or do individuals who behave in a way that increases their individual risk of developing CVD often come from a lower socio-economic group?

I'll concede that if the former is true, that would be a valid reason to provide risk-reducing medication to people from that socio-economic group.

 

[Darat]

Overweight and obese people should be treated for their weight problem, not given medication to mitigate the risks of staying overweight or obese. The same goes for all unhealthy behaviours within the control of the individual.

So what happens when, as I said at the beginning of this, a fat person just misses the "target" weight that you've decided is "good" and their cholesteral level and ratio is still not ideal - in your system they are stuffed (pun intended)!

Does being in a lower socio-economic group increase their individual risk of developing CVD, or do individuals who behave in a way that increases their individual risk of developing CVD often come from a lower socio-economic group?

I'll concede that if the former is true, that would be a valid reason to provide risk-reducing medication to people from that socio-economic group.

I've just had a look if I kept the link and I didn't - but in a debate awhile ago someone did bring up a study that showed that for many classes of diseases (including CVD) social-economic grouping is a "risk factor" regardless of other criteria such as weight, smoking and so on.

But you are again being inconsistent- if I am in a "lower" social economic group I can change my life to change that just like I can change my life if I am fat so why is it only if I'm fat you would not allow me free statins?