The Cost of Going to JUPITER

Every now and then a study gets published that grabs everyone’s attention. Not just in the media-frenzy kind of way, but truly affecting clinical practice. Several months ago, the JUPITER trial caused a mini-earthquake in medicine, especially in endocrine, cardiology, and general practice clinics all over the country. The trial was performed in people with overall normal cholesterol levels, but high markers of inflammation, namely hsCRP. The study was concluded early because of the significant advantage in terms of cardiovascular end points seen in the group receiving Rosuvastatin, the study drug used in this trial. Within days of the study results hitting the news, I was flooded with patients newly placed on this medication by their primary providers.

For years there has been a long running half-joke that if the statin data continues to be so supportive on the whole, pretty soon we’ll be dumping statins into the water supply. We had started moving away from the statins-can-cure-everything mode for awhile, but with the JUPITER trial this seems to be returning somewhat. The magic about the study was that these were folks with both “normal” cholesterol levels and absence of known cardiovascular disease. Overall, we would think of this as a low-risk group aside from their having elevated hsCRP levels. Seeing such a benefit in a low-risk group raises the question many people are asking now: who doesn’t need to be on a statin?

The study supports a creeping claim that there is no floor for LDL goals given that we now have a few studies showing ongoing improvement with continued lowering of LDL. Below 100? Great! Below 70? Even better!

Aside from the obvious contraindications to statin use such as liver dysfunction or prior myopathy with exposure, there seems to be fewer and fewer reasons not to use them for primary prevention. Recall that, amid uproar, the American Academy of Pediatrics last year made a recommendation that stain therapy be considered for children with very elevated cholesterol levels and high-risk of future cardiac events based on positive family history and comorbid disease. Kids now! Where are we going with this stain madness?

The even larger question of having stations over the counter is looming. At first my gut feeling was, “No way, bad idea. We’ll have a rash of myopathies coming into ERs because of inappropriate dosing of the drug.” Then I remembered that the safety profile for statins is actually quite good. Rosuvastatin, being the most potent statin on the market is the most likely to cause side effects if inappropriately dosed, but this is not the one headed for possible OTC use. But even so, who is to say that they should be guarded more vigilantly than other medications that are now OTC? We have accepted the risk of NSAIDS over the counter, the GI bleeds, ulcer disease, and rare hemorrhages. Tylenol, probably one of the most often used medications in planned overdoses, is over the counter. Having ANY medications available to the general pubic without guidance of a physician or pharmacist means we place great responsibility into the hands of adults to use the medications appropriately, whether it be stains in the future, or Afrin now.

I am deep in thought about the stats of our love affair with statins. Not just for my patients, but also for my family and myself. My husband and I are fast approaching the magic 40, and both of us have strong family histories of cardiac disease. If statins do become OTC soon, I may be ready to bite the bullet then and start a low dose, even though my most recent cholesterol was picture perfect. If the data is right, most of us live on JUPITER, and life may be better with a statin…