Comment: Empirical evidence, not eminence, and certainly not dogma

The following is a comment/letter to the editor to the online article, “Some catalysts for debate on statins“, published in Medical Observer.  This article covered two somewhat opposing perspectives by Prof Kerryn Phelps, and Prof James Tatoulis to the controversial ABC Catalyst program on the role of lipids and statins on health.  The shorter online response was published on 20 November 2013, and an expanded version was published in the final volume of Medical Observer in 2013.

Empirical evidence, not eminence, and certainly not dogma.

What we know about empirical evidence is that conjectures and suppositions extrapolated from cherry-picked data points, pathophysiological rationale, or anecdote, are often misleading and not “useful” – insofar as being able to make correct predictions of the future.

As per the commentary by Prof Tatoulis, the evidence that exists on the effectiveness of statins is robust – perhaps even as robust as we can/should reasonably demonstrate in medical research. It is vastly more reliable than the evidence for many interventions that we would claim to be “evidence-based”.

It is true nonetheless that we do not have good quality evidence on some of the milder side-effects of statins. These may not be dangerous, but have important impacts on quality of life and must be captured in future studies on statins. We know that the benefit of statins in individuals at lower cardiovascular disease risk is small – very much smaller in absolute terms than those at high risk. As such, side-effects that might be considered to be not terribly important in high risk situations take on a greater importance and meaning.

We need to recognise that in our therapeutic interactions with patients as general practitioners, it is this construction of meaning that is essential. The evidence is the BEGINNING, and not the end. We need to interpret the evidence within our local scenarios and contexts. We need to take account of patient values and preferences, and use our clinical expertise.

That being said, for shared decision making to be meaningfully constructed in the patient’s best interests, it must be grounded in empirical evidence and not wishful thinking.