Side Effect Patterns in a Crossover Trial of Statin, Placebo, and No Treatment
James P Howard, Frances A Wood, Judith A Finegold, Alexandra N Nowbar, David M Thompson, Ahran D Arnold, Christopher A Rajkumar, Susan Connolly, Jaimini Cegla, Chris Stride, Peter Sever, Christine Norton, Simon A M Thom, Matthew J Shun-Shin, Darrel P Francis, James P Howard, Frances A Wood, Judith A Finegold, Alexandra N Nowbar, David M Thompson, Ahran D Arnold, Christopher A Rajkumar, Susan Connolly, Jaimini Cegla, Chris Stride, Peter Sever, Christine Norton, Simon A M Thom, Matthew J Shun-Shin, Darrel P Francis
Abstract
Background: Most people who begin statins abandon them, most commonly because of side effects.
Objectives: The purpose of this study was to assess daily symptom scores on statin, placebo, and no treatment in participants who had abandoned statins.
Methods: Participants received 12 1-month medication bottles, 4 containing atorvastatin 20 mg, 4 placebo, and 4 empty. We measured daily symptom intensity for each using an app (scale 1-100). We also measured the "nocebo" ratio: the ratio of symptoms induced by taking statin that was also induced by taking placebo.
Results: A total of 60 participants were randomized and 49 completed the 12-month protocol. Mean symptom score was 8.0 (95% CI: 4.7-11.3) in no-tablet months. It was higher in statin months (16.3; 95% CI: 13.0-19.6; P < 0.001), but also in placebo months (15.4; 95% CI: 12.1-18.7; P < 0.001), with no difference between the 2 (P = 0.388). The corresponding nocebo ratio was 0.90. In the individual-patient daily data, neither symptom intensity on starting (OR: 1.02; 95% CI: 0.98-1.06; P = 0.28) nor extent of symptom relief on stopping (OR: 1.01; 95% CI: 0.98-1.05; P = 0.48) distinguished between statin and placebo. Stopping was no more frequent for statin than placebo (P = 0.173), and subsequent symptom relief was similar between statin and placebo. At 6 months after the trial, 30 of 60 (50%) participants were back taking statins.
Conclusions: The majority of symptoms caused by statin tablets were nocebo. Clinicians should not interpret symptom intensity or timing of symptom onset or offset (on starting or stopping statin tablets) as indicating pharmacological causation, because the pattern is identical for placebo. (Self-Assessment Method for Statin Side-effects Or Nocebo [SAMSON]; NCT02668016).
Keywords: crossover trial; drug intolerance; nocebo; side effects; statins.
Conflict of interest statement
Funding Support and Author Disclosures This study was funded by the British Heart Foundation (PG/15/7/31235), which had no role in study design, data collection, data analysis, data interpretation, or writing of the report. This study was supported by the National Institute for Health Research Imperial Biomedical Research Centre (BRC) and the Imperial Clinical Trials Unit. The views expressed are those of the author and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. Dr Howard is supported by the Wellcome Trust, grant number 212183/Z/18/Z. Dr Nowbar is supported by the National Institute for Health Research Academy. Dr Rajkumar is supported by the Medical Research Council, grant number MR/S021108/1. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.
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References
- Toth P., Granowitz C., Hull M., Philip S. Long-term statin persistence is poor among high-risk patients with baseline peripheral artery disease: a real-world administrative claims analysis of the Optum Research Database. J Am Coll Cardiol. 2019;73(9 Suppl 1):1744. doi: 10.1016/s0735-1097(19)32350-2.
- Toth P.P., Granowitz C., Hull M., Anderson A., Philip S. Long-term statin persistence is poor among high-risk patients with dyslipidemia: a real-world administrative claims analysis. Lipids Health Dis. 2019;18:175. doi: 10.1186/s12944-019-1099-z.
- Mantel-Teeuwisse A.K., Goettsch W.G., Klungel O.H., De Boer A., Herings R.M.C. Long term persistence with statin treatment in daily medical practice. Heart. 2004;90:1065–1066. doi: 10.1136/hrt.2003.026187.
- Stulc T., Ceška R., Gotto A.M. Statin Intolerance: the Clinician’s Perspective. Curr Atheroscler Rep. 2015;17(12):69. doi: 10.1007/s11883-015-0552-3.
- Stroes E.S., Thompson P.D., Corsini A. Statin-associated muscle symptoms: impact on statin therapy-European Atherosclerosis Society Consensus Panel Statement on Assessment, Aetiology and Management. Eur Heart J. 2015;36:1012–1022. doi: 10.1093/eurheartj/ehv043.
- Mihaylova B., Emberson J., Blackwell L. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: Meta-analysis of individual data from 27 randomised trials. Lancet. 2012;380:581–590. doi: 10.1016/S0140-6736(12)60367-5.
- Goldfine A.B. Statins: is it really time to reassess benefits and risks? N Engl J Med. 2012;366:1752–1755. doi: 10.1056/NEJMp1203020.
- Finegold J.A., Manisty C.H., Goldacre B., Barron A.J., Francis D.P. What proportion of symptomatic side effects in patients taking statins are genuinely caused by the drug? Systematic review of randomized placebo-controlled trials to aid individual patient choice. Eur J Prev Cardiol. 2014;21:464–474. doi: 10.1177/2047487314525531.
- Gupta A., Thompson D., Whitehouse A. Adverse events associated with unblinded, but not with blinded, statin therapy in the Anglo-Scandinavian Cardiac Outcomes Trial—Lipid-Lowering Arm (ASCOT-LLA): a randomised double-blind placebo-controlled trial and its non-randomised non-blind extension phase. Lancet. 2017;389:2473–2481. doi: 10.1016/S0140-6736(17)31075-9.
- Colloca L., Miller F.G. The nocebo effect and its relevance for clinical practice. Psychosom Med. 2011:598–603. doi: 10.1097/PSY.0b013e3182294a50.
- van Buuren S., Groothuis-Oudshoorn K. mice: multivariate imputation by chained equations in R. J Stat Softw. 2011;45:1–67. doi: 10.18637/jss.v045.i03.
- Maas C.J.M., Hox J.J. Sufficient sample sizes for multilevel modeling. Methodology. 2005;1:86–92. doi: 10.1027/1614-2241.1.3.86.
- Wood F.A., Howard J.P., Finegold J.A. N-of-1 trial of a statin, placebo, or no treatment to assess side effects. N Engl J Med. 2020;383:2182–2184. doi: 10.1056/nejmc2031173.
- Nissen S.E., Stroes E., Dent-Acosta R.E. Efficacy and tolerability of evolocumab vs ezetimibe in patients with muscle-related statin intolerance: the GAUSS-3 randomized clinical trial. J Am Med Assoc. 2016;315:1580–1590. doi: 10.1001/jama.2016.3608.
- Herrett E., Williamson E., Brack K. Statin treatment and muscle symptoms: Series of randomised, placebo controlled n-of-1 trials. BMJ. 2021;372:n135. doi: 10.1136/bmj.n135.
- Parker B.A., Capizzi J.A., Grimaldi A.S. Effect of statins on skeletal muscle function. Circulation. 2013;127:96–103. doi: 10.1161/CIRCULATIONAHA.112.136101.
- Nissen S.E. Statin denial: an internet-driven cult with deadly consequences. Ann Intern Med. 2017;167:281–282. doi: 10.7326/M17-1566.
- Barron A.J., Zaman N., Cole G.D., Wensel R., Okonko D.O., Francis D.P. Systematic review of genuine versus spurious side-effects of beta-blockers in heart failure using placebo control: Recommendations for patient information. Int J Cardiol. 2013;168:3572–3579. doi: 10.1016/j.ijcard.2013.05.068.
- American College of Cardiology The American College of Cardiology Statin Intolerance Tool.
- Mach F., Baigent C., Catapano A.L. 2019 ESC/EAS guidelines for the management of dyslipidaemias: Lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41:111–188. doi: 10.1093/eurheartj/ehz455.
- NHS England Statin intolerance pathway.
- National Institute for Health and Care Excellence Lipid modification - CVD prevention - NICE CKS.
- Benedetti F., Lanotte M., Lopiano L., Colloca L. When words are painful: unraveling the mechanisms of the nocebo effect. Neuroscience. 2007;147:260–271. doi: 10.1016/j.neuroscience.2007.02.020.
- Prescription Cost Analysis - England 2018 [PAS] - NHS Digital.
- Vickers A.J. The use of percentage change from baseline as an outcome in a controlled trial is statistically inefficient: a simulation study. BMC Med Res Methodol. 2001;1:1–4. doi: 10.1186/1471-2288-1-6.
Source: PubMed