狼醫專門為我寫了回貼，我很感激，這肯定是為了幫助我漸進式地接近真相。

狼醫專門為我寫了回貼，我很感激，這肯定是為了幫助我漸進式地接近真相。

先回應您最後的那句話。我的原話是“我同意這個原作者，不見得是出於他個人利益在這麽說，他不過是產業鏈裏最下麵那個成員。” 這如何變成了 “每一個醫生都在謀財害命”。。。喔喔喔，我可但當不起哦。我當時其實是還有半句沒說出來的: “不過是產業鏈裏最下麵那個成員，要分也分不到半杯羹”。但是既然是我偷懶省去了，話沒說全，冒犯了醫生，也不能怪您生氣。所以先解釋一下。

 

1。兩張圖

首先要問的是：什麽導致了那個持續上升的肥胖率？這個現象後麵的本質是啥?

當然有很多說法。我現在唯一要點到的是：同一時期大力提倡普及的飲食指南是食物金字塔。

 

減少吸煙，降血壓，降血脂：它們各自的影響力是多少呢？

按照WHO Monica調查分析，導致心血管疾病的主要因素是吸煙而不是高膽固醇，80%的心血管疾病由吸煙、缺乏運動、不健康飲食、不健康生活方式造成。所以當吸煙大大減少時，死亡率下降是可以預期的。Framingham的調查也顯示，運動量最多的那部分人的死亡率低於運動量最低的那部分人40%

高血壓降下來的作用也是減少死亡率的原因，對這個沒有異議。

這兩條曲線我覺得可能體現了因果關係。

 

至於血脂呢，這些年它下降的趨勢肯定是不用看任何資料就知道的。因為他汀普及覆蓋麵那麽大，米國人隻要有保險和家庭醫生做體檢的，一旦血脂偏高，一定被他汀，跑不掉的。而這些藥能確實有效地降血脂。我還可以預測，將來它還會更走低。

 

問題是：降下來的血脂，到底對死亡率的下降有多大的影響呢？這個圖表上當然看不出來。要去看那些臨床試驗數據。

 

那麽導致CHD死亡率下降的還有沒有其他的因素？

溶栓藥物

手術， angioplasty等

急救技術上的飛躍發展

這些是否有貢獻？

 

2。扯蛋磚家是誰？我去搜了下，原來是個英國人。這個扯蛋說法後麵的實質是個重要的問題：他汀作為一度預防的使用範圍應該多廣，該如何來決定？

 

Dr John Reckless, chairman of Heart UK and a consultant endocrinologist at Bath University

 

Increasingly, doctors are suggesting statins should be given to people with risk factors but

no obvious disease, which is called primary prevention. This is to prevent disease occurring in the first place.

 

But is the threat of cardiovascular disease so great that statins may as well be added to the water supply?

 

This was the debate held recently by doctors at the annual meeting of Heart UK - a patient and science charity for cholesterol.

Mass treatment

Dr John Reckless, chairman of Heart UK and a consultant endocrinologist at Bath University, put forward the case.   http://news.bbc.co.uk/2/hi/health/3931157.stm

 

3 和4。他汀多有效？是否副作用少？

 

這個問題要掰開講的話就得翻那些實驗文獻了。對我來說很難，很花時間。我不知道你指的那些著名實驗具體是那些。我對他汀的療效還沒有係統去了解過，我所粗率知道的是WOSCOPS，AFCAPS/TexCAPS，4S，ENHANCE，LIPID，CARE，ALLHAT，PROSPER，Heart Protection Study，ProveIt，JUPITER。我主要關注的數據是absolute risk的減少，而不是relative risk，還有那個NNT數字。

舉個例子吧：如果看下麵這5個實驗，PROSPER,

ALLHAT-LLT, ASCOT-LLA, AFCAPS and WOSCOPS, statin drugs provided an Absolute 

Risk Reduction in total mortality of 0.3%.

您若是推薦具體的實驗文獻，我肯定是會找時間去看的。看不看得出門道來也難說，隻能是去慢慢地學罷了。

 

他汀的副作用：我以前知道的是肌肉痛，性欲減低等這些普遍的副作用。

還知道那個吃Lipitor吃得完全失憶的NASA宇航員醫生，寫了“Lipitor Thief of Memory”這本書的作者Duane Graveline。

 

但是最近看到的是一些以前不知道的副作用，如糖尿病（他汀導致胰島素抗拒，血糖升高）

 

這算是個綜述：

The Ugly Side of Statins. Systemic Appraisal of the Contemporary Un-Known Unknowns

http://file.scirp.org/Html/3-1980073_34065.htm

(這篇文章裏引用的那些研究我還沒去查過對照過。)

 

還有這個他汀與癌症的動物實驗:

Carcinogenicity of Lipid-Lowering Drugs

Data Synthesis. —All members of the two most popular classes of lipid-lowering drugs (the fibrates and the statins) cause cancer in rodents, in some cases at levels of animal exposure close to those prescribed to humans. In contrast, few of the antihypertensive drugs have been found to be carcinogenic in rodents. Evidence of carcinogenicity of lipid-lowering drugs from clinical trials in humans is inconclusive because of inconsistent results and insufficient duration of follow-up.

 

Conclusions. —Extrapolation of this evidence of carcinogenesis from rodents to humans is an uncertain process. Longer-termclinical trials and careful postmarketing surveillance during the next several decades are needed to determine whether cholesterol-lowering drugs cause cancer in humans. In the meantime, the results of experiments in animals and humans

suggest that lipid-lowering drug treatment, especially with the fibrates and statins, should be avoided except in patients at high short-term risk of coronary heart disease.(JAMA. 1996;275:55-60)

 http://jama.jamanetwork.com/article.aspx?articleid=393579

 

對是否貼這個文獻我猶豫了很久。最終貼出來，是覺得：癌症形成過程挺長，而他汀臨床試驗期一般不會超過5年。至於大量病人常年吃他汀，隨著年齡越來越老，若是有癌症出現，要厘清它與他汀到底有何關係是不那麽輕易的。這屬於我所說的：真相未知。對於沒有心髒病但血脂高的那個群體，我覺得這種研究在決定是否吃藥預防心血管病時是應該拿來做個參考的。

 

另外貼一個對新的NCEP膽固醇治療新指南所依賴的那些實驗數據的分析

Analysis

Should people at low risk of cardiovascular disease take a statin?

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6123 (Published 22 October 2013)

http://www.bmj.com/content/347/bmj.f6123

 

 

5。醫生／專家與藥廠的關係，我隻想舉下麵這個例子，其他的不想拿出來多說，免得被人誤解成我對醫學／科學持仇視態度。我若是不相信科學，不會去花這麽多時間尋找原始資料來自學。但是我不迷信科學：醫生科學家是人不是神。

 

對您，和壇子裏其他的醫生科學家們我是尊敬的。很欣賞你們對壇友許多問題的耐心解答。

 

 

寫2001 NCEP膽固醇指南的委員會裏的專家們：

Scott M.Grundy, MD, PhD (Chair of the panel), Diane Becker, RN, MPH, ScD, Luther T.

Clark, MD, Richard S. Cooper, MD, Margo A. Denke, MD, Wm. James Howard, MD,

Donald B. Hunninghake, MD, D. Roger Illingworth, MD, PhD, Russell V. Luepker,

MD, MS, Patrick McBride, MD, MPH, James M. McKenney, PharmD, Richard C.

Pasternak, MD, Neil J. Stone, MD, Linda Van Horn, PhD, RD

 

他們的 financial disclosure:

Dr Grundy has received honoraria from Merck, Pfizer, Sankyo, Bayer, and Bristol-Myers

Squibb. Dr Hunninghake has current grants from Merck, Pfizer, Kos

Pharmaceuticals, Schering Plough, Wyeth Ayerst, Sankyo, Bayer, AstraZeneca,

Bristol-Myers Squibb, and G. D. Searle; he has also received consulting

honoraria from Merck, Pfizer, Kos Pharmaceuticals, Sankyo, AstraZeneca, and

Bayer. Dr McBride has received grants and/or research support from Pfizer,

Merck, Parke-Davis, and AstraZeneca; has served as a consultant for Kos

Pharmaceuticals, Abbott, and Merck; and has received honoraria from Abbott,

Bristol-Myers Squibb, Novartis, Merck, Kos Pharmaceuticals, Parke-Davis,

Pfizer, and DuPont. Dr Pasternak has served as a consultant for and received

honoraria from Merck, Pfizer, and Kos Pharmaceuticals, and has received grants

from Merck and Pfizer. Dr Stone has served as a consultant and/or received

honoraria for lectures from Abbott, Bayer, Bristol-Myers Squibb, Kos

Pharmaceuticals, Merck, Novartis, Parke-Davis/Pfizer, and Sankyo. Dr Schwartz

has served as a consultant for and/or conducted research funded by

Bristol-Myers Squibb, AstraZeneca, Merck, Johnson & Johnson-Merck, and

Pfizer.

 

目前我的認識是：他汀對二度預防是有效果的。所以不能說他汀是毒藥；但即使在二度預防上，它也不是仙丹。這是否接近真相，有待時間證實，也期待新資料的修正。