Statins, antidepressants and end-of-life care: journals update October 2016

Recent research of interest to GPs.

Cholesterol crystals: Patients need to be given clearer information about statins
Cholesterol crystals: Patients need to be given clearer information about statins

Statin therapy benefits outweigh potential risk1

Statins rarely seem to be out of the headlines and as a consequence, many patients are fearful and anxious about taking this type of medication. The aim of this study was to consolidate all of the available robust evidence into one clear paper, with the aim of improving understanding and increasing compliance.

Study design
This review discussed the objective strengths and weaknesses of RCTs and observational studies. It then considered all of the specific available evidence for the efficacy and safety of statin therapy, including data from the large-scale Cholesterol Treatment Trialists’ Collaboration meta-analysis, which included statistics concerning 25,000 major cardiovascular events.

Key findings
Statin therapy reduces cardiovascular risk. There is a 10% absolute benefit in secondary prevention and 5% absolute benefit in primary prevention. Conversely, myopathy is the only serious adverse event shown to be caused by long-term statin therapy.

It is estimated that over a five-year period, five patients per 10,000 will develop myopathy. Contrary to popular belief, RCTs have shown definitively that almost all symptomatic adverse events that are attributed to statin therapy are not actually caused by taking them.

Implications for GPs
It is of great concern that exaggerated claims about statin therapy abound. The risks of myopathy are rare, whereas the potential life-saving benefits of taking statins are well substantiated.

The public health implications for poor compliance in patients taking statins are potentially significant.This study was widely reported in the mainstream press and it is to be hoped that it will improve patient confidence in statins, allowing for better and clearer discussions.

The right time to stop antidepressants2

Although guidelines suggest that antidepressants should be discontinued after six to 18 months in cases of anxiety disorder and four to 12 months in depression, half of the UK patients prescribed antidepressants take them for more than two years.

Until now, the reasons behind this have not been explored. The cost and healthcare implications to general practice are significant, given that an estimated 40m prescriptions for antidepressants are issued each year.

Study design
This qualitative study carried out in the Netherlands recruited 30 patients, paired with their own GPs. Patients had to have been taking antidepressants for longer than six months and be in remission from their anxiety/depressive symptoms. In-depth interviews were carried out separately with the patient and the GP, and the resulting information was analysed.

Key findings
Both patients and GPs cited various conflicting reasons as to why stopping antidepressants was difficult. Despite this, more than half of the GPs believed patients were better off without medication. GPs and patients alike worried about stopping antidepressants following previous failed attempts.

Discussions revealed suboptimal communication between patients and GPs, and a lack of awareness as to who had responsibility to guide discussions about stopping treatment.

Implications for GPs
This study acts as a good reminder that our perception of patients’ thought processes are not always accurate. Exploring patients’ concerns and views regarding antidepressant use is worthwhile and may lead to more successful discontinuation.

The study also makes a good case for having a more definite treatment plan, including a clear agreement as to where responsibilities lie.

E-cigarette use and smoking cessation3

There has been growing concern that the rapid rise in the use of e-cigarettes could undermine patients’ quitting activities. This is primarily due to the potential fall in use of more traditional treatments, alongside structured support programmes.

This study attempted to assess whether e-cigarettes are hampering smoking cessation, or prompting patients to try to quit.

Study design
Data were collated from the Smoking Toolkit Study and NHS Stop Smoking services.

Key findings
The study found that e-cigarette use was positively associated with successful quit rates. The success rate of quit attempts increased by 0.098% for every 1% increase in the prevalence of e-cigarette use. However, there was no clear evidence that the availability of e-cigarettes encouraged more patients to attempt to quit. There also appeared to be a link between e-cigarettes and a fall in NRT on prescription.

Implications for GPs
If the findings of this study are to be believed, e-cigarettes could have a significant impact on smoking cessation rates nationally.

Extrapolating the figures, the study authors suggest that e-cigarette use could result in an extra 18,000 long-term ex-smokers. With the corresponding evidence that e-cigarettes have resulted in fewer NRT prescriptions, this positive public health impact could occur with little or no financial burden to the NHS.

How planning tools can improve discussions about end-of-life care4

We have an increasingly ageing population, but many GPs feel uncertain about recognising frailty.

In addition, there are many other problems inhibiting end-of-life planning discussions, such as time constraints, uncertainty over benefits and inadequate consultation skills.

end-of-life care
Discussing end-of-life care can be constrained

Study design
Using the Supportive & Palliative Care Indicators Tool, 62 suitable patients from four practices were identified. GPs presented the patients with information regarding end-of-life planning in the form of the ‘Think Ahead’ tool. Patients were then contacted by telephone after one week and three weeks, to discuss their thoughts about the information.

Key findings
The overwhelming majority of patients read the literature supplied and found it a positive experience. However, it did not prompt a significant increase in the number of end-of-life discussions between patients and family members. Of note, 17% of those responding found reading the information upsetting.

Implications for GPs
Anecdotally, the GPs involved found the tool helpful in identifying frail patients entering the final stages of life. Given the known difficulties and inaccuracies in predicting death and discussing end-of-life care, these sorts of tools may be worth using in a more routine and widespread fashion.

High risk of non-stroke morbidity with AF5

AF is the most common sustained cardiac arrhythmia and incidence rates are increasing year on year. Historically, the primary focus in the management of patients with AF has been stroke prevention, but current thinking suggests it is linked to IHD and chronic kidney disease.

Study design
A total of 104 cohort studies were included in the analysis, involving 9,686,513 patients.

The study found there was a 46% increased risk in all-cause mortality owing to AF. There was a significantly increased risk of IHD (61%), chronic kidney disease (64%), sudden cardiac death (88%) and major cardiovascular events (96%). The risk of congestive heart failure was the highest out of all the outcomes measured, even stroke (see table).

Risks associated with AF
Outcome Risk
Cardiovascular mortality x 2
Stroke x 2.3
Incident congestive heart failure x 5

Implications for GPs
This study supports the growing evidence that AF is linked to a number of other morbidities. Although there is no clear evidence that AF causes cardiovascular disease, it may act as a marker or risk factor. Greater understanding of these links needs to be established, allowing the development of interventions to reduce non-stroke outcomes in AF.

  • Dr Jessica Garner is a GP in Worcester

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References

  1. Lancet, September 2016
  2. BJGP, June 2016
  3. BMJ 2016; 354: i4645
  4. BJGP, September 2016
  5. BMJ 2016; 354: i4482

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