Should women be prescribed statins?

Women in western countries are more likely to die from heart disease than from cancer.

In this week's BMJ, two experts debate whether women should be offered cholesterol lowering drugs as a preventive treatment.

For women who are at moderately high risk of heart disease, use of drugs should not be ruled out, argues Professor Scott Grundy from the University of Texas.

There is general agreement that both men and women with established cardiovascular disease are at high risk and should get intensive cholesterol lowering therapy.

The essential question here is whether women as well as men should be considered for drug therapy when they do not have established cardiovascular disease, but who are deemed to be at moderately high risk, according to the guidelines.

Trials involving both men and women at moderately high risk have shown overall risk reduction from cholesterol lowering therapy, but not enough women were included to provide a definitive result, he explains.

Until a large-scale clinical trial is carried out to test the efficacy of cholesterol lowering in women at moderately high risk, drug therapy should be avoided in most lower risk women, he says. But in those who have multiple cardiovascular risk factors and who are projected to be at moderately high risk, use of drugs should not be ruled out.

But GP Malcolm Kendrick disagrees. Not only do statins fail to provide any overall health benefit in women, they represent a massive financial drain on health services, he says.

He believes the evidence of benefit is not strong enough. He points out that, to date, none of the large prevention trials has shown a reduction in overall mortality in women, and one suggested that overall mortality may actually be increased. This, he says, raises the important question whether women should be prescribed statins at all.

Statins also represent the single greatest drug expenditure in the National Health Service, he says. In 2006, the cost in England was £625m and is expected to reach £1bn in 2007. This money could be diverted to treatments of proved value.

Some studies also suggest that statins carry a substantial burden of side effects, he adds.

He concludes that spending hundreds of millions on a treatment that has no proved benefit and may cause serious harm goes against the rationale of evidence based prescribing.

www.bmj.com/