June 3, 2013

expert reaction to statin use and musculoskeletal problems

A report published in JAMA Internal Medicine suggested taking statins may be associated with musculoskeletal conditions, joint diseases and injuries.

Helen Williams, Consultant Pharmacist for Cardiovascular Disease, Royal Pharmaceutical Society, said:

“What the paper shows is that most people get musculoskeletal disorders, in particular musculoskeletal pain whether they are on statins or not! The impact of statins here is very small, increasing the risk of musculoskeletal disorders overall from 85% in those not on statins to 87% on a statin.

“My concern is the impact this report may have on adherence.  In the UK we have around 5 million people taking statins to prevent heart attacks and strokes. If 1% of these patients stop taking their statins due to concerns about muscle pains – we will see at least 2000 more heart attacks and strokes over the next 10 years as a result, but only avoid 1000 musculoskeletal problems.

“Patients should be reassured that musculoskeletal disorders occur commonly – but they are rarely due to taking statins.   Different statins have different effects on the muscles, so it patients are experiencing muscle pains due to a specific statin – a different statin should be tried.  Patients with concerns should discuss these with their doctor or pharmacist.”

Professor David Spiegelhalter, Winton Professor of the Public Understanding of Risk, University of Cambridge, said:

“It would be easy, but wrong, to interpret this study as if a rare and important adverse event has a 19% increased risk.  In fact 87% in the statin users have some musculo-skeletal diagnoses, compared with 85% in the matched non-users, so almost everyone has this supposed “adverse event”.  The difference between the groups is trivial and I believe completely explainable by statin users being examined more frequently.”

Professor Kevin McConway, Professor of Applied Statistics, The Open University, said:

“The researchers had to study many thousand people to find what’s actually a very small difference. The events they were looking at are very common: most of the people they studied had had a diagnosis of a musculoskeletal condition over the period of the study, whether or not they had taken statins – 87% of the statin users had a diagnosis, compared to 85% of the non-users.  And the researchers certainly haven’t shown that taking statins was the cause of the difference they found. There are many other possibilities. Doctors might make different diagnoses for people they know to be on statins – we’re told that the group on statins was examined more often. The use of propensity score matching sounds impressive, and it’s certainly a way of allowing for differences between statin users and non-users that has nothing to do with the effects of the statins. But it can’t allow for things that weren’t used for the matching, and the variables used for matching are only part of the picture. If the tiny increase in diagnoses were really due to the statins, I’d have expected there to be an effect of the length of time patients had been taking them, but there wasn’t.”

Dr Tim Chico, Senior Clinical Lecturer and honorary Consultant Cardiologist, University of Sheffield / Sheffield Teaching Hospitals, said:

“This study showed that people on statins were slightly more likely to have musculoskeletal problems, but the increase was tiny and it is not definite this was due to the statins anyway. Musculoskeletal problems are unfortunately very common; in this study 85% of people not on statins had some kind of musculoskeletal problem, with similar issues seen in 87% of people on statins. This means that if you are on statins, and you get a musculoskeletal problem, it’s probably nothing to do with the statin; you were going to get it anyway.

“It is clear from other studies that statins do increase some types of musculoskeletal problems, particularly muscle aches, and these can be very troublesome. What is also clear is that statins save lives when used in the right type of patient, generally those at higher risk of stroke or heart attack because of other medical problems. Any medical decision has to balance the risk of side effects or complications with the benefit the treatment provides. This is as true for statins as it is for antibiotics for chest infections or hip replacements. With statins the benefits are hidden; many people were going to have a heart attack today that was prevented by their statin treatment, but they will never know. Unfortunately, the side effects of statins are often all too obvious, and this biases many people against a potentially life-saving tablet.

“The days of people taking a drug just because their doctor tells them to are happily long gone. No-one should be taking any drug unless they understand why they are taking it, what the benefits might be, and what side effects can occur. My job is to give people this information, and let them decide if they want to take a drug, and I don’t mind at all if once properly informed my patients choose not to take statins; everyone is different in their acceptance of medical treatments and what they are prepared to go through to reduce their risk of heart disease. But if I had a heart attack, it would take pretty bad muscle aches for me to not take a statin long term to reduce my risk of having another heart attack.

“The search for drugs to lower cholesterol levels without inducing musculoskeletal side effects is still going on, and there are some promising new agents being tested in clinical trials right now. But we are unlikely to ever find a drug that provides benefit without any risk of side effects.”

‘Statins and musculoskeletal conditions, arthropathies, and injuries’ by Ishak Mansi et al. published in JAMA Internal Medicine on Monday 3 June.