COMMENT:THE FAT QUESTION

The latest drugs which look like making a fortune for the drugs industry are those designed to lower blood cholesterol levels.

For years now many doctors and patients have believed that a patient who has a high blood cholesterol level will be more likely to suffer from heart trouble, high blood pressure or a stroke.

Millions of pounds have been spent on screening patients for blood cholesterol levels. Many patients have been frightened half to death by finding out that their blood cholesterol levels were too high.

Between 1986 and 1990 the number of prescriptions for cholesterol lowering drugs trebled in the United Kingdom.

For the health service and for governments all around the world the prescribing of cholesterol lowering drugs will be an expensive business. A huge proportion of the apparently healthy population will be turned into regular pill takers. The profits for the international drug companies will run into billions.

But, putting aside the fact that many people might be able to correct their blood cholesterol levels simply by eating more sensibly, are the risks associated with their long time use acceptable?

The answer is that no one really knows.

Despite the fact that these drugs are already being prescribed in huge quantities, no one yet knows for certain whether these drugs are really worth prescribing.

Some trials already seem to suggest that some of the patients who take cholesterol lowering drugs may be more not less likely to die. Indeed, some trials seem to suggest that simply lowering the blood cholesterol level may not always be wise.

Consider the following facts:

A recent report in the British Medical Journal (15 Feb 1992) concluded that “various studies have shown excess mortality from injuries” and “causes not related to illness” in those who have participated in trials in which their serum cholesterol concentration is lowered by either diet or drugs’.

Researchers looked into the possibility that a low cholesterol level may be linked to death from injury or suicide.

They found that death from injuries, particularly suicide, was commoner in some men with a low cholesterol level.

Dr Hyman Engelberg, of the Department of Medicine, Cedars-Sinai Medical Centre, Los Angeles recently wrote an article in The Lancet (21 March 1992)which began: “…trials which have shown that the lowering of serum cholesterol concentrations in middle aged subjects by diet, drugs or both leads to a decrease in coronary heart disease have also reported an increase in deaths due to suicide or violence. There has been no adequate explanation for this association.”.

Dr Engelberg suggested that a lowered serum cholesterol concentration may contribute to a “poorer suppression of aggressive behaviour”.

A World Health Organization trial (see WDDTY Vol 3 No 8) of the drug clofibrate reduced expectations that cholesterol lowering drugs might lower mortality from heart disease and raised new questions about the role of these drugs.

A BMJ editorial (15 Aug 1992) posed the question: “Since the clofibrate appeared to increase the risk of death should it still be available for treating lipid [blood cholesterol] disorders?”

Matthew G Dunnigan, Consultant Physician at Stobhill General Hospital in Glasgow concluded that “the lack of evidence of significant reductions in all causes of mortality by lipid lowering drugs, particularly in primary prevention trials, indicates that any favourable effect of lipid lowering drugs on all causes of mortality is at best small and of only marginal benefit to the individual.”

Some doctors have even argued that a cholesterol level that is too low may lead to a high cancer risk.

Instead of wasting millions of pounds on cholesterol lowering drugs which probably do patients more harm than good, perhaps we ought to be putting more effort into trying to find out what causes cholesterol and the effects of the drugs we’re handing out in an attempt to lower it.

Dr Vernon Coleman is editor of the European Medical Journal.