Without even listing to this discussion, I expect Dr. Cobble will conclude that statins are wonderful drugs with little risk of side effects, even diabetes, and that almost everyone should take statins.   

This is based on observation of his consistent, frequent and sometimes lengthy comments to other HeartWire articles about statins. His comments consistently attempt to counter any other commentators who suggest that statins don't really work that well or may pose risks.

If you want a balanced, impartial analysis of statins, this is not likely it.  If my prediction (above) turns out to be wrong, then my apologies.

Dear Jerry-

Thanks for taking time to post a comment.  We offer up discussions like this to get some dialogue going in the community about important, and sometimes controversial, topics of relevance to the science and care of cardiovascular patients.  Please go ahead, listen to the conversation and let us know your thoughts.  We definitely don't need to always agree with one another to learn and to make progress in the field.  Thanks again.

Bob  

Bob, Michael,

I enjoyed the podcast and agreed with most of the sentiments expressed, and I hope that most readers would agree that in the published papers we stressed that CVD benefit comfortably outweighed DM risk in the populations studied to date. Clearly in secondary prevention and higher risk primary prevention we should be using these excellent medications. The data do suggest the need to be more vigilant for new-onset diabetes particularly on intensive regimens.

I think the more interesting questions are:

1. What about patients with chronic heart failure, a condition in which diabetes risk is high & where statins have as yet not shown benefit?

2. What about patients at ever lower CVD risk in primary prevention? Given that atorvastatin is off-patent, we might see intensive therapy being used in such groups. And, for example, in JUPITER there were about 7 new cases of DM for every 10 major CVD events (by that I mean CVD death, NFMI, NF stroke [revasc excluded]) prevented. So clearly there is CVD benefit, but DM numbers are not insignificant. High dose atorvastatin in SPARCL was similar, with approx 9 new cases DM for 10 CVD prevented (same definition above). That isn't to say that a new diagnosis of DM is equivalent to a CVD event, but it puts things in perspective.

3. Mechanisms

 Disclosure: co-author on recent meta-analyses

since we dont know how statins may initiate diabetes the best we can do now is stratify people according to risk of becoming diabetic.

checking A1-c, cholesterol levels,  microalbuminuria........age etc, in other words dont just check for cardiovascular risk but check for pre-diabetes!

If you do this statins can offer: decreased risk of various cancers (in men of prostate esp post primary therapy)

risk reduction for Alzheimers (esp for those with APo-E)

CVD risk reduction!!

Long term use of statins appear to be safe and dont increase cancer risk.

if patient is on other medications consider non CYP statins (newer ones like rosuvastatin)

and more important LIFESTYLE CHanges! Plant based diet and EXERCISE (if possible)

High dose statins can reverse coronary disease but there is some evidence that low dose statins and a plant based diet can do the same thing!