A woman, 31, went to her doctor for a routine checkup in May. Her lab report showed cholesterol levels outside the normal range (LDL: 117 milligrams per decilitre of blood (mg/dL); TG: 255 mg/dL; HDL: 37 mg/dL). She smokes around five cigarettes a day. Her doctor prescribed her a statin, a drug that acts to reduce cholesterol levels in the blood, for six months. After that, they would retest her blood.
Was the doctor right?
India is in the middle of a statin over-prescription and under-prescription crisis. Rich, urban folks—the ones who can afford private hospitals in big cities—are being oversold statins. Meanwhile, poor and rural Indians, who ought to be on the pills, are not.
“There is a fair amount of inappropriate prescription of statins, both ways,” said Prem Pais, dean and professor of medicine at St. John’s Medical College in Bengaluru. “[Doctors] just go, ‘Here’s somebody who smokes and has a little high [cholesterol], let’s give her statins’. You [also] have people who have had heart attacks and are not given statins.”
At the heart of the over-prescription crisis is a debate over who qualifies for treatment. There is little doubt within the medical community that statins should be given to heart patients. But what about the people who don’t yet have heart disease? How much cholesterol can an Indian have in her blood before a doctor judges it dangerous and prescribes her statins to prevent a potential heart attack or stroke? Surprisingly, this is more a matter of educated opinion than strong evidence. There is little data about heart disease in Indians, so most doctors go by international guidelines instead.
But now, an association of doctors from some of the biggest private hospitals in India has come up with a consensus statement on managing cholesterol. The recommendations, put forth by the Lipid Association of India (LAI) in 2016, are the most aggressive in the world. They suggest cutting LDL levels in heart disease patients to below 50 mg/dL. That’s 20 mg/dL lower than the most-stringent international guideline, currently followed in Europe. They also recommend lowering the threshold for defining patients at risk of developing heart disease.
The recommendations, if followed, would bring millions of Indians under screening or treatment. More than 30 million people have coronary artery disease in India, and even more people are at risk.
These guidelines would also potentially earn the pharmaceutical industry millions in revenue. Some Rs 2,625 crore ($373 million) worth of statins were sold in India in the year ending June 2018.