The jury is still out on the value of statins in H5N1 (see posts here and here). But these drugs seem to have many beneficial effects and are taken by a huge proportion of the at risk population to lower their cholesterol. But a new study suggests not as many are taking them as want to or might. The barrier is money.:
Many patients taking statins to lower their cholesterol stop taking the drugs because of co-payments and shared drug costs, a new study found.These drugs, which have been shown to prevent heart attacks, should be fully covered by insurance, said study lead researcher Dr. Sebastian Schneeweiss, an associate professor of medicine and epidemiology at Harvard Medical School.
"There are a bunch of conditions, like high cholesterol, where patients should be totally exempted from any cost-sharing just in order for them to take the medication," Schneeweiss said. "The patient's health will be better, but it also makes economic sense for the insurance plan -- if the plan is thinking not just about the pharmacy cost but the overall costs. The cost to insurance companies to treat a heart attack is far more than the cost to prevent one." (Health Day via medicinenet)
The temptation to cut a drug that treats no symptoms a person can feel and is mainly preventative is strong when there are other imperatives. But the insurance company saves money in the long run. Heart disease is costly to treat once it has reached the stage where it is causing symptoms. At the same time there is some evidence statins have other benefits as well. Things like this are just another indication the health insurance system is broken.
The statin/influenza question is more compliated. Whether statins prevent serious complications of influenza remains to be seen. However the most at risk population in a pandemic will be younger people, whose rate of statin use is very low or non-existent. Statins are plentiful and in generic form relatively inexpensive and if we find further evidence they are effective in preventing the worst complications of H5N1 (cytokine storm), we might consider advising prophylactic use among a younger population should a pandemic take hold and follow the pattern of 1918 and the existing H5N1 cases: high virulence and preference for younger victims. But it would be a tricky call. Statins have a relatively good safety profile but when taken by tens of millions, serious side effects are certain to occur, principally in the liver, although in a young age group we might see more or different adverse reactions.
It's a balancing act. The risks are certainly worth it if the alternative is a sepsis-like reaction to H5N1. But like a vaccine, it would be given to healthy young people, before they are sick with the flu. An adverse reaction in a healthy young person is more devastating than in someone already desperately ill.
But then so is influenza.
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Hmmm, a quick look on Pubmed suggests that very little research has (unsurprisingly) been performed on possible side effects of statin use in otherwise healthy young people.
It may be the case that this should remain a "trade secret" of clinicians who can use it when they believe it is necessary, rather than a broad public health program. But then again, perhaps statins act too slowly to be useful when administered in crisis situations. A difficult question to ponder given the uncertainty.
I am just loathe to add another black box to the already crowded Rubik's cube public health planners face. (hmmm, there is a good metaphor in there somwhere: "Imagine a Rubik's Cube where most of the squares were black....that is what planning for an influenza pandemic is like")
Jon,
On the other hand, if all the squares are black, there is little incentive to get the lines to match up.
Well, we don't know if statins reduce the risks from influenza, but a new study is saying something that clinicians sort-of know: that flu vaccine reduces heart attacks.
http://www.timesonline.co.uk/tol/news/uk/health/article1668527.ece
I haven't read the study, but as the Times report says
"Flu infection is thought to cause acute inflammation that can destabilise atherosclerotic plaques in the arteries."
the by-now urgent question is, does it work the other way round? ie if the influenza virus causes inflammatory responses in blood vessels that statins can oppose/prevent, could the same or similar inflammatory processes in younger patients be causing the severe pulmonary complications in primary infections, such as what we are seeing with H5N1? If yes, would the effects of statins be similar?
If they are beneficial, we don't know whether they could work even in the short term. When we are talking about millions and millions of people, even a very modest reduction in mortality could translate to huge numbers.
SusanC
Looking at it from the other direction if flu causes destabilisation of atherosclerotic plaques would this not cause a massive surge in strokes during a flu pandemic? Is there data to support increased strokes in people with high cholesterol levels, beyond that which would be expected from any other disease which put a similar level on of strain on its victims?
JJackson,
It's an interesting thought, but I haven't seen anything reported in that way. But of course, as we all know, data on previous pandemics, even on pandemic deaths, are sketchy, let alone deaths by other causes. I don't expect much help there, to be honest.
There are also some studies that indicate they may reduce the risks of glaucoma.
I've been taking pravastatin for several years and just had my eyes checked; my inter-ocular pressure is below average, indicating lower risk of glaucoma.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&li…
CONCLUSIONS: Initial examination of an administrative clinical database indicates the intriguing possibility that long-term use of oral statins may be associated with a reduced risk of open-angle glaucoma, particularly among those with cardiovascular and lipid diseases. Nonstatin cholesterol-lowering agents were also associated with a reduced risk of having open-angle glaucoma. Additional investigation is warranted as to whether these classes of agents may provide an additional therapeutic addition for glaucoma.
Susan
I was thinking more in terms of data from seasonal flu.
I was not expecting much data from 1918, they had a few other things to worry about at the time. I assume that the numbers of people emerging from WW1 with cholesterol build would have been negligible compared with today. These days if a sizeable percentage of people with fatty arteries had strokes during a pandemic it would not bode well for a healthcare system already at, or beyond, breaking point.
As I posted on the other thread, I think there are legitimate grounds for concern about statin use, partly based on the anecdotal evidence of friends and family, who have reported muscle cramping/pain and cognitive deficits whose onset and remission coincided with starting and stopping statin use.
There's also a lot of muttering about statin use triggering ALS or ALS-like symptoms in many individuals, to wit:
http://www.spacedoc.net/ALS_statins.html
There are other things, too, that trigger major alarm bells for me about statins. A good friend recently decided to stop taking statins, and when a medical professional (not his regular doctor) asked why, he replied that he had been having major side effects. My friend also pointed out that his cholesterol was only about 140, which the Mayo clinic had said was well within normal range. "But they've revised the guidelines," said the doctor. "Now you're supposed to get below 100. Of course," added the doctor, "no normal person would ordinarily have cholesterol that low, so that's where the statins come in..." There's a whiff of something unsavory about all this, IMHO.
Well, maybe ordinary vegetarians have cholesterol almost that low? ;-)
revere: any chance you could weigh in on the
"statins cause ALS" meme?
i'm on em. i get the shooting pains. my labs are all fine. just heard about this speculation.
my folks, both medical professionals, say,
"pick your poison--stroke or ALS. /grin/."
TIA.