The pros and cons of a daily polypill
Should all over-50s take a preventive drug? A debate in Britain could have messages for treatment more broadly. Here’s what the experts say.
Popping a single daily pill from our 50s onwards could prevent thousands of heart attacks and strokes, according to researchers from University College London’s institute of Health Informatics.
Reporting in the BMJ, Professor Aroon Hingorani, a co-author of the paper, says that taking a four-in-one polypill, which combines a statin to lower cholesterol and three blood pressure-lowering drugs, could replace the NHS’s five-yearly health assessment for cholesterol and heart health that targets adults aged 40-74.
“A population-wide approach could prevent many more heart attacks and strokes than the current strategy of targeting a limited group only,” Professor Hingorani says.
Professor Bryan Williams, chief scientific and medical officer of the British Heart Foundation, says the thinking outlined in the new paper is that “by treating more people with a multipill, you get a bigger bang for your buck” in terms of disease prevention. But, he points out, the constituents of a polypill are readily available and “are as good as what is being proposed in a multipill”. And given that the combined pill is not a regulated treatment in the UK, for a polypill to be produced and prescribed on the National Health Service, he says, “There would be some regulatory hurdles to jump to show the precise combination is effective and that individual components have not been compromised.”
A polypill is already available privately. Nicholas Wald, professor of preventive medicine at University College London and one of the authors of the BMJ paper, is listed as director of an online polypill prevention program that has been running on a private basis (accessed on polypill.com) for more than 10 years in the UK. But what are the pros and cons of us all taking one?
Is a daily pill a viable alternative to regular health checks?
About 15 million people in England are eligible for the free five-year check that assesses aspects of diet and lifestyle, height, weight and blood pressure, and usually involves blood tests to check for abnormal cholesterol levels, diabetes and kidney problems.
According to NHS England, the consultations detect undiagnosed high blood pressure in 1 in 27 people and diagnoses of diabetes in one in 110 people, and one in 8 who undergo the checks are found to be at high risk of a stroke or heart attack. But the NHS health checks are effective only if you take them, which many do not.
“Only four in ten people are taking up the offer of an appointment,” Professor Hingorani says. Not everyone agrees that a population-wide polypill program is the answer. Professor Williams says that “statins and blood pressure-lowering drugs can definitely prevent heart disease and save lives”, but adds that the idea of everybody above the age of 50 taking a combined pill is questionable. “With a polypill the same dose of medications would be prescribed to everyone who takes it.”
Can one pill cut heart disease risk?
Last year Anubha Agarwal, assistant professor of medicine in the Cardiovascular Division of Washington University School of Medicine, reviewed data from 26 clinical trials and found that the polypills were associated with an 11 per cent lower risk of death from any cause and a 29 per cent lower risk of atherosclerosis cardiovascular disease events compared with people who did not take them. “These findings support adoption and implementation of polypills to lower risk for all-cause mortality for cardiovascular disease,” she reported in the journal Nature Medicine.
Are there any side-effects?
Possibly, although the authors of the new BMJ report stress that potential side-effects including “dizziness or falls from low blood pressure” could be overcome by “monitoring symptoms every 20 weeks before issuing a repeat prescription”.
Reported side-effects also include cough, muscle aches and upset stomach, with a trial conducted at Queen Mary, University of London showing 29 per cent of people experienced side-effects compared with 13 per cent on placebo.
“Side-effects to medications are very individual,” says Dr Jonathan Behar, a consultant cardiologist at Guy’s and St Thomas’ Hospitals. “It could be that some people do experience more with a single pill.”
Do the benefits outweigh the risks?
According to the authors of the BMJ paper, a national program would require only 8 per cent of those eligible in Britain to take up the offer of taking a daily pill to achieve greater benefit than NHS checks. But Williams says it is not that straightforward and too early to consider scrapping health checks in favour of routine polypill prescription for the over-50s.
“The reality is that existing statins and blood pressure medications prescribed to at-risk people have very few adverse side-effects. But if even a tiny percentage of those on a more widespread prescription of polypills present with concerns or side-effects it could result in a massive number of additional NHS requests.”
The Times
