Under-reporting or over-reporting?

I am going to start part two by looking at the evidence for statins causing ‘non-imagined’ adverse effects. Or, to put it another way, real effects. My own view on this is that the adverse effects of statins are significantly under-reported. Mainly because patients often don’t associate the drug with the problem. Such as muscle pain or weakness. This is especially true if it takes weeks or months for problems to develop. In some cases, even years.

Even if patients do report symptoms, doctors do not record many, if any, of the adverse effects. Which is true of all drugs, not just statins. The US does have an adverse drug reaction reporting system. But less than 1% of adverse reactions are captured by it ¹:

As the article confirms: ‘Underreporting significantly delays the dissemination of critical information about such reactions.’ You don’t say.

In the UK, we have a yellow card system, specifically designed to make it a complete pain to report any problems. If you do fill in a yellow card, you find yourself bombarded with requests for masses of additional information. Past medical history, drug history, days and dates of starting the medication, exact adverse effect, lab tests etc. etc. This can all take many, many, unpaid, hours to gather. Which means that doctors rarely bother to use the system, and patients have never even heard of it.

The issues of adverse effect reporting has many other complexities. A few years ago, an interesting study caught my eye. It was not large, but telling. I have not seen the same research done, before or since. I may have missed it. It can be tricky to keep up with all the research done. Seventy-five patients were taking blood pressure lowering tablets – anti-hypertensives. They were asked the following questions:

1. Did their quality of life improve on medication?
2. Did it stay the same?
3. Did it get worse?

Two other groups, the patient’s doctor, and the patient’s closest relative/partner were asked the same questions … about the person taking the tablets.

A little background. High blood pressure causes no symptoms. Because of this, hypertension is often referred to as the ‘silent killer’. Anti-hypertensives, on the other hand, are well known for causing a number of unpleasant effects. Therefore, you would probably expect that taking anti-hypertensives would have a negative effect on quality of life. Or, at best, it would remain about the same. Here is how the three groups answered.

Doctors:                      Quality of life improved:                                  100% agreed

Patients:                      Quality of life improved:                                  50% agreed

Patient’s relatives:      Quality of life improved:                                  0% agreed

Possibly most telling is that seventy-four out of seventy-five of the patient’s relatives reported that the quality of life worsened ². What can we learn from this? Well, I might start by giving the doctors involved a good slap. I wouldn’t learn anything, but it might be a good lesson in humility for them. ‘Stop seeing what you want to see, and start seeing what is.’

The point here is that if there is a significant bias in the reporting of adverse effects, the bias is heavily weighted towards not reporting them. Not by patients, and certainly not by the doctors – remember that 1% figure. Which means that nothing is recorded for posterity. See no evil, hear no evil, speak no evil.

Another issue in play here, specifically, is that the authors of the Lancet paper do not appear to have heard of the placebo effect:

The placebo effect is a phenomenon where a person’s physical or mental health improves after receiving an inert, “dummy” treatment (like a sugar pill or saline injection). Triggered by the belief in, and expectation of, improvement, the brain induces real, measurable physiological changes—such as releasing endorphins or dopamine—that reduce symptoms like pain, fatigue, and anxiety.

One of the main reasons why we have such massive, complex, double-blind placebo-controlled trials is precisely because of the placebo effect. The drug could initially appear brilliant, but it may be achieving nothing; it may be that the ‘placebo effect’ is doing the heavy lifting.

Because of this significant ‘confounding factor’ clinical trials need to be ‘controlled’ by giving everyone a pill, or an injection. A percentage get the active drug, the rest get the dummy placebo. It is a major reason why clinical trials are so huge, complex, and costly.

However, the impact of taking an unknown ‘placebo’ is far less than being handed a real tablet by a doctor. Who will likely inform you, with great enthusiasm, that it is going to do you good ³. Especially if they add, as they do with statins. ‘And it will stop you dying from heart disease.’ Or words to that effect. [And if you dare stop taking it, you will die].

Strangely, it appears to have escaped the attention of the CTT in Oxford that there is such a thing as the placebo effect. For them, the only bias that exists with statins is that you read about nasty effects, then suffer from them. The Nocebo effect. Why did they not mention the placebo effect? Which does the exact opposite – far more powerfully. I leave it to you, dear reader, to decide on that matter.

Some evidence of causality

It is very difficult to know what the true rate of adverse effects with statins may be. So much heat, so very little light. I cannot possibly cover all adverse effects in this blog. Instead, I will focus primarily on muscle pain and damage. This is probably the most common problem, and the most easily explained and understood.

I want to make it exceedingly clear that, far from being an imagined problem, we have a well-established biochemical pathway that directly links from statins to muscle damage, pain and weakness. With all steps proven, multiple times, in multiple studies.

In its simplest form, the pathway goes like this. Statins block an enzyme known as HMG-CoA reductase. This inhibits an early step in the long and complex – thirty-six step process – that ends up with the synthesis of cholesterol. This mainly takes place in the liver, which synthesizes around five grams of cholesterol, per day. About twenty eggs worth.

However, if you block HMG-CoA reductase this is not the only pathway you inhibit. You are also blocking the production of many other highly important compounds at the same time. You can perhaps think of cholesterol synthesis as a tree that grows from the ‘root’ of a chemical compound called Acetyl CoA.

As the chemical reaction ‘tree trunk’ grows upwards it starts to branch out, leading to the creation of many other, vital, substances. Such as dolichols, Heme A, prenylated proteins, co-enzyme Q10 etc, etc. Don’t worry there won’t be a test at the end.

Forgetting the others, important though they are, I will focus on Co-enzyme Q10 here. Which is also known as ubiquinone. This co-enzyme is critical in the synthesis of Adenosine Triphosphate (ATP). This molecule is, in turn, the power source that drives everything in our bodies. When ATP is broken down to ADP, energy is created, and used. This is how we work. From ‘professor’ Wikipedia:

‘ATP (adenosine triphosphate) is the primary energy carrier and “molecular currency” of the cell, storing and transferring energy to power essential processes like muscle contraction, nerve impulses, chemical synthesis, and active transport.’

You could think of ATP as the fuel in our car, or the battery in an EV. ATP doesn’t’ last long, and is being constantly replenished within the mitochondria – the little energy factories that live inside our cells. But without ATP, everything stops, and you die.

So, you could say it is kind of important. And, yes, statins have a significant and detrimental effect on the production of coenzyme Q10 (CoQ10), and then on ATP production. If you want some ‘real’ boring science about what this does. Read this paper:

‘Simvastatin impairs ADP-stimulated respiration and increases mitochondrial oxidative stress in primary human skeletal myotubes ⁴.’

‘These data demonstrate that simvastatin induces myotube atrophy and cell loss associated with impaired ADP-stimulated maximal mitochondrial respiratory capacity, mitochondrial oxidative stress, and apoptosis (death) in primary human skeletal myotubes, suggesting that mitochondrial dysfunction may underlie human statin-induced myopathy (muscle damage and pain).’

Paper highlights – taken from the paper itself:

• Statins can induce muscle weakness/myopathy.
• In culture, simvastatin induced dose dependent atrophy of human myotubes.
• Statin exposure decreased mitochondrial respiratory function and increased ROS (reactive oxygen species…ROS = ’bad’) production.
• Activation of apoptosis (muscle cell death) also evident.
• Findings suggest mitochondrial dysfunction underlies statin-induced myopathy.

It all sounds pretty damned unpleasant, does it not. The primary problem is that, without sufficient CoQ10 mitochondria cannot make enough ATP. This, in turn, ‘impairs ADP-stimulated respiration’ which leads to mitochondrial dysfunction then activation of apoptosis. Apoptosis means cell death.

In short. If the mitochondria can’t make enough ATP, the cell does not have enough ATP/energy to survive, and may commit suicide. Which is what ‘activation of apoptosis’ means.

You think the pharmaceutical companies didn’t notice this… this (imaginary) muscle cell destruction and death? Of course they did. They may be many things, most of which are far too rude to print here, but they are very good at science, and they certainly do notice stuff.

They knew very early on that statins block CoQ10 synthesis, and then ATP synthesis. Not entirely, but up to a fifty per-cent reduction. At one point it looked as if this could be such a significant problem that Merck took out two patents outlining how to neutralise it. The first was US4933165A:

Key Aspects of US4933165A

• Assignee: Merck & Co., Inc.
• Inventor: Michael S. Brown (Note: The patent is often associated with the work of Dr. Karl Folkers regarding CoQ10, though the listed assignee in the 1990 publication is Merck).
• Purpose: The invention describes a method for reducing the side effects of HMG-CoA reductase inhibitors (statins) by combining them with Coenzyme Q10.
• Mechanism: Statins work by blocking the HMG-CoA reductase pathway. This same pathway is used by the body to produce CoQ10. The patent addresses the depletion of CoQ10 caused by statins, which can lead to muscle pain (myopathy) and potential heart damage.
• Scope: The patent covers the combination of CoQ10 with various statins, including lovastatin, simvastatin, and pravastatin.

They didn’t act on this patent. Perhaps it wasn’t seen as a great sales idea to stuff the antidote into the same packet as the statin. ‘These are perfectly safe, you say. So, what it this other tablet here for – precisely?’

One man who did take out a patent with regard to the muscle damage caused by statins was none other then Professor Sir Rory Collins himself, in 2009.

A leading Oxford medical researcher who says statins are safe is at loggerheads with a company that makes “misleading” claims about the drugs’ side effects to sell a diagnostic test he invented.

More than 6m people take statins — drugs which reduce cholesterol and save an estimated 7,000 lives a year — but there is a fierce debate about the benefits and side effects.

Sir Rory Collins, a professor of medicine and epidemiology at Oxford University, led a review into statins, published in The Lancet earlier this month, which found that not more than one in 50 people will suffer side effects.

Collins, who believes millions more Britons could benefit by taking statins, is also co-inventor of a test that indicates susceptibility to muscle pain from them.

In 2009, he and three co- inventors filed the patent for a genetic marker that identifies patients at increased risk of myopathy (muscular pain). The patent says the incidence of myopathy is around one in 10,000 patients per year on a standard statin dose*.

The test, branded as Statin–Smart, is sold online for $99 (£76) on a website that claims 29% of statin users will suffer muscle pain, weakness or cramps. The marketing material also claims that 58% of patients on statins stop taking them within a year, mostly because of muscle pain.

Oxford University said Collins had raised his concerns “several times” about “misleading” marketing claims made by Boston Heart Diagnostics, the American company granted the exclusive licence for Collins’s patent by the university⁵. [Lois Rogers was health editor for the Sunday Times].

*Muscle pain and myopathy are not quite the same thing. Myopathy is a serious adverse effect – assocatied with a significant rise in an enzyme called creatine kinase (CK). When muscles are damaged and/or, die they – usually – release enzymes, with CK being the main one. Myopathy can be the precursor to rhabdomyolysis (very widespread muscle death) which has an extremely high fatality rate. And yes, all statins can cause rhabdomyolysis – albeit rarely.

I think of it this way, as a spectrum.

Muscle pain                =          Moderate muscle damage/death ± moderate rise in CK

Myopathy                    =          Severe muscle damage (often, not always, a rise in CK)

Rhabdomyolysis          =         Catastrophic muscle damage, CK through the roof

Myopathy may be considered relatively rare 1:10,000 per year (according to Collins). But the diagnosis is not straightforward, and it is heavily reliant on the finding of raised CK levels. But…here is a small study looking at patients with severe myopathy, and no rise in CK. ‘Statin-associated myopathy with normal creatine kinase levels.’

‘Four patients with muscle symptoms that developed during statin therapy and reversed during placebo use… Muscle biopsies showed evidence of mitochondrial dysfunction…These findings reversed in the three patients who had repeated biopsy when they were not receiving statins. Creatine kinase levels were normal in all four patients despite the presence of significant myopathy ⁶.’

So, we have a condition that is considered rare … but which may not be as rare as you think it is. Because you are relying on a blood test that may, or may not, actually diagnose it. You may get a lot of false negative tests. [A test which says you do not have a condition, when you do]. And when does muscle pain transform into myopathy? It is arbitrary.

Enough of this, I think.

What do we now know? We know that statins block CoQ10 production, and this reduces the amount of ATP being manufactured by the mitochondria – by up to fifty per cent. This is a well-researched, and inarguable, scientific fact. It will be a particularly significant problem in cells that have a high energy requirement e.g. skeletal muscle, or heart muscle, or neurones.

In truth, the adverse effect issue mainly boils down to this. Do you have the reserves to overcome the mitochondrial damage that statin cause … or not. If you do have the reserves, you may not notice much, if anything. If you don’t, you could end up stuck in a chair, hardly, able to rise. Which I have seen happen to several patients. And my father-in-law. An early statin user.

One lady I was looking after in an elderly care unit was judged to be so physically and mentally incapacitated that she was going to be admitted to a nursing home with frailty and dementia. I stopped the statins, and she walked out of the unit two weeks later, bright as a button. The nurses were stunned. I got a letter from her GP a week later, condemning me for stopping her life saving medication. That was just one of many patients where I had very similar results. She was just the most dramatic.

Do I have other terrible tales about statins? Of course. I recall another lady with such severe abdominal pain that she ended up having a laparoscopy (sticking a camera into the abdominal cavity to have a look around). Nothing was found, a mystery. She stopped the statin, on my recommendation, and the pain went away. Completely and forever.

Yes, I am biased, yes these are ‘anecdotes’, easily dismissed – and, boy, they will be. But I have seen so very many. Far more cases of rhabdomyolysis, for example, than I should ever have seen in my career …statistically.  And so many more have written to me, telling me how they have suffered, and then been dismissed by their own doctors.

Here is one such. I could dredge up a thousand more, given a couple of days.

‘Thank you, Dr. Kendrick. I am one of the many unfortunates who suffered permanent muscle damage from a needless prescription of simvastatin from 2008 to 2012. No monitoring, but my CK reading of 20 x normal was discovered by chance and the alarm was raised. When referred to NHS specialists their attitude was very strange, complete denial and hostility. Now permanently disabled on the right side of my body.’ Georgina H (Reproduced with consent).

Before I finish this blog. I would like to return to my court case, and all the interesting documents that emerged, blinking into the light. Barney Calman was the Health Editor of the Mail on Sunday which ran the defamatory article against me. He put out a call for case histories from people who had stopped taking statins, then suffered a major event e.g. heart attack, or stroke, or suchlike. What he got was the following:

From: Barney Calman Sent: Tue, 26 Feb 2019 08:44:40 +0000From: “Barney Calman” To: “Fiona Fox” , “Rory Collins” , “Colin Baigent” , “samanin@bhf.org.uk” , “Sever, Peter S” , “Liam Smeeth” CC: “Greg Jones” Thread To: Fiona Fox Rory Collins Cc: Greg Jones Sensitivity: Normal Colin Baigent samanin@bhf.org.uk Sever, Peter S Liam Smeeth

‘Dear all, thank you again for all your input into this article so far. I wanted to readdress the issue of finding a case study. One of the key factors in your collective argument is that criticism of statins discourages use amongst high-risk patients, and this is a public health threat. Since putting calls out we have been inundated by stories of people who have stopped taking statins and felt far healthier.

We’ve had two quite dramatic stories of patients who have been taken off statins by their doctors because of developing serious liver problems, and then died. The families themselves both naturally question whether statins caused the problems. What we haven’t had is a single story which backs your thesis, and obviously I’m concerned.’

Yes, he was ‘inundated’ with stories of people who felt far better having stopped their statins. The only two case histories he had managed to get hold of, at this point, were two people who took statins which then (almost certainly) caused liver failure, then death. [Statins are known to cause liver failure leading to, in extreme cases, death].

One would hope, in an ideal world, that if an investigative journalist was running a story on the unrivalled benefits of taking statins, and the harm that would befall those who stopped taking them … then. Then, when he found himself literally, his word, ‘inundated’ with stories of people who felt far better after stopping statins, and two cases of people who were almost certainly killed by statins then … Then you may pause to wonder if you are grabbing the right end of the stick.

But no, he did not let this put him off in the slightest. He had his eyes on the prize.

Next, a few surprising facts about statins and the unpleasant effects they can cause. Before finally, my direct criticism of the Lancet paper. And the nonsense that it is.

1: https://www.ncbi.nlm.nih.gov/books/NBK599521/

2: http://www.ncbi.nlm.nih.gov/pmc.articles/PMC1971011/pdf/jroyalcgprac00086-0041.pdf

3: Unraveling the mystery of placebo effect in research and practice: An update – PMC

4: https://www.sciencedirect.com/science/article/abs/pii/S0891584911011130

5:Statins expert in row over level of risk to patients – Lois Rogers

6: Statin-associated myopathy with normal creatine kinase levels – PubMed