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Why the stats about statins don't tell the whole story

For those without the relevant risk factors, statins aren't the wonder-pill they've been sold as by the media.

Maggie came hot-foot from a “health check” where she’d had her cholesterol measured. “Six point two!” she told me. “The nurse said that’s high.” She sounded rather spooked. “I’d like you to give me a statin.”

I’ve known Maggie for years. She’s a sensible academic in her early fifties. She’d done enough googling to learn that a “high” cholesterol means you are “at risk” of cardiovascular disease (CVD) – heart attacks and strokes – and that statins lower cholesterol and reduce CVD risk by 25 per cent. Her request for treatment made perfect sense to her . . . except she had fallen for the same myth that leads to several million people in the UK swallowing a statin every day for no good reason at all.

Focus for a moment on that 25 per cent risk reduction. If you’re at high risk of something nasty, then lopping off a quarter of that risk makes sense. The people at greatest risk of heart attacks and strokes are those who have previously suffered one. Giving statins to these patients (secondary prevention) does convey modest benefits. If you take 100 heart attack survivors and get them to take a statin for five years, you’ll save one life, prevent two or three non-fatal heart attacks, and avert one stroke. That is worthwhile, even if the statins will fail to prevent at least 15 other heart attacks/strokes, and will cause two patients to develop diabetes, and provoke muscle weakness in ten others. Notice, though: 95 per cent of these highest-risk patients will derive absolutely no benefit from their five years of statin consumption.

Come back to Maggie. Using a statin on someone without existing CVD is termed primary prevention. Maggie has no other risk factors (high blood pressure, smoking, diabetes, and so on) and so her chance of developing heart disease is very low. In Maggie’s case, because her risk is so small to start with, a 25 per cent reduction is minuscule and meaningless. You’d have to treat hundreds of Maggies for years on end to hope to make a jot of positive difference to one of them, and the side effects from statins (we’re still discovering what these are) will far outweigh any putative benefit.

There are large numbers of people just like Maggie who are taking statins and who should come off the tablets. But what about individuals at greater risk – people with high blood pressure or obesity, or smokers? Is there a level of risk at which primary prevention is worthwhile? For some time the UK’s National Institute for Health and Clinical Excellence (NICE) has suggested a threshold of 20 per cent risk over ten years.

At first glance, the trial data does suggest a marginal impact at this sort of level: roughly two heart attacks/strokes are averted among 100 people treated for five years. But, crucially, death rates are not altered; no lives are saved by using statins. This probably reflects the harm also caused by statins, and how any small reduction in CVD is negated by disability and death from other causes.

Taking up regular exercise, or adopting a Mediterranean diet, reduces CVD risk by degrees comparable with statins – in the case of diet, substantially more so. If someone smokes, quitting is similarly helpful. What’s more, once one has adopted these lifestyle changes, statins become virtually redundant. Lifestyle modification is also cheap; there are very few harms besides. And, unlike with statins, these measures protect against other causes of death and disability, such as cancer and the frailties of advancing age. Oh, and they’re good for mental health, too.

This February, NICE initiated a consultation on halving its primary prevention threshold to 10 per cent risk. If achieved, this would add hugely to the six million people in the UK who take statins on prescription. Rather than exacerbate our statin fetish, NICE could design simple decision aids that would help doctors understand the more effective improvements that lifestyle changes can bring to health and well-being – and which would illustrate these benefits to patients.

Once we’d talked things through, Maggie resolved to start attending the university gym a few times a week. She decided to forget the statin prescription, too. As a nation, we’d do well to try the same. 

This article first appeared in the 26 February 2014 issue of the New Statesman, Scotland: a special issue

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The answer to the antibiotics crisis might be inside your nose

The medical weapons we have equipped ourselves with are losing their power. But scientists scent an answer. 

They say there’s a hero in everyone. It turns out that actually, it resides within only about ten percent of us. Staphylococcus lugdunensis may be the species of bacteria that we arguably don’t deserve, but it is the one that we need.

Recently, experts have cautioned that we may be on the cusp of a post-antibiotic era. In fact, less than a month ago, the US Centres for Disease Control and Prevention released a report on a woman who died from a "pan-resistant" disease – one that survived the use of all available antibiotics. Back in 1945, the discoverer of penicillin, Alexander Fleming, warned during his Nobel Prize acceptance speech against the misuse of antibiotics. More recently, Britain's Chief Medical Officer Professor Dame Sally Davies has referred to anti-microbial resistance as “the greatest future threat to our civilisation”.

However, hope has appeared in the form of "lugdunin", a compound secreted by a species of bacteria found in a rather unlikely location – the human nose.

Governments and health campaigners alike may be assisted by a discovery by researchers at the University of Tubingen in Germany. According to a study published in Nature, the researchers had been studying Staphylococcus aureus. This is the bacteria which is responsible for so-called "superbug": MRSA. A strain of MRSA bacteria is not particularly virulent, but crucially, it is not susceptible to common antibiotics. This means that MRSA spreads quickly from crowded locations where residents have weaker immune systems, such as hospitals, before becoming endemic in the wider local community. In the UK, MRSA is a factor in hundreds of deaths a year. 

The researchers in question were investigating why S. aureus is not present in the noses of some people. They discovered that another bacteria, S. lugdunensis, was especially effective at wiping out its opposition, even MRSA. The researchers named the compound created and released by the S. lugdunensis "lugdunin".

In the animal testing stage, the researchers observed that the presence of lugdunin was successful in radically reducing and sometimes purging the infection. The researchers subsequently collected nasal swabs from 187 hospital patients, and found S. aureus on roughly a third of the swabs, and S. lugdunensis on up to 10 per cent of them. In accordance with previous results, samples that contained both species saw an 80 per cent decrease of the S. aureus population, in comparison to those without lugdunin.

Most notably, the in vitro (laboratory) testing phase provided evidence that the new discovery is also useful in eliminating other kinds of superbugs, none of which seemed to develop resistance to the new compound. The authors of the study hypothesised that lugdunin had evolved  “for the purpose of bacterial elimination in the human organism, implying that it is optimised for efficacy and tolerance at its physiological site of action". How it works, though, is not fully understood. 

The discovery of lugdunin as a potential new treatment is a breakthrough on its own. But that is not the end of the story. It holds implications for “a new concept of finding antibiotics”, according to Andreas Peschel, one of the bacteriologists behind the discovery.

The development of antibiotics has drastically slowed in recent years. In the last 50 years, only two new classes of this category of medication have been released to the market. This is due to the fact almost all antibiotics in use are derived from soil bacteria. By contrast, the new findings record the first occurrence of a strain of bacteria that exists within human bodies. Some researchers now suggest that the more hostile the environment to bacterial growth, the more likely it may be for novel antibiotics to be found. This could open up a new list of potential areas in which antibiotic research may be carried out.

When it comes to beating MRSA, there is hope that lugdunin will be our next great weapon. Peschel and his fellow collaborators are in talks with various companies about developing a medical treatment that uses lugdunin.

Meanwhile, in September 2016, the United Nations committed itself to opposing the spread of antibiotic resistance. Of the many points to which the UN signatories have agreed, possibly the most significant is their commitment to “encourage innovative ways to develop new antibiotics”. 

The initiative has the scope to achieve a lot, or dissolve into box ticking exercise. The discovery of lugdunin may well be the spark that drives it forward. Nothing to sniff about that. 

Anjuli R. K. Shere is a 2016/17 Wellcome Scholar and science intern at the New Statesman