Since the pandemic, I’ve noticed a distinct—shall we say?—”evolution” in many doctors who initially started out as COVID-19 contrarians, such as, for example, Paul Marik. First, they went “anti-lockdown” and anti-public health interventions, portraying COVID-19 as not nearly as dangerous as public health physicians, scientists, and officials were warning in 2020. Then, when the vaccines rolled out, they became anti-COVID-19 vaccine, while insisting that they were not antivaccine, just anti-this vaccine. Then, unsurprisingly and in contrast to their denials, they further “evolved” to become more generally antivaccine, regurgitating antivax false claims that I (and others) were debunking as long as two decades ago, including the claim that vaccines cause autism and sudden infant death syndrome (SIDS). The final stage of the “evolution” of these doctors is that they just go full quack, which his why it’s rather interesting that just a couple of days ago I wrote about Dr. Paul Marik, co-founder of the anti-public health Frontline COVID-19 Critical Care (FLCCC) Alliance going full cancer quack repeating old cancer quack tropes about how chemotherapy for cancer supposedly doesn’t work, except rarely. Of course, the same “evolution” has held true for Dr. Marik’s buddy and co-founder of FLCCC, Dr. Pierre Kory, who, as you will see, has gone all-in on anti-statin quackery.
First, however, here’s a reminder of his antivax proclivities.
Dr. Kory has now chosen another form of quackery besides cancer quackery, as I learned the other day when antivax leader turned independent Presidential Candidate Robert F. Kennedy, Jr. Tweeted this out:
What, however, is Dr. Kory claiming? Let’s take a look at the thread that RFK Jr. amplified:
Citing the pseudonymous and anonymous Substack antivax crank A Midwestern Doctor (AMD), whom I like to call, given his embrace of many forms of quackery (antivax and other), A Midwestern Quack (AMQ)? Not a great look! Of course, these days, although AMQ tries very hard to remain anonymous, I strongly suspect that he/she/it must have been an “integrative medicine” quack before the pandemic; so I don’t count AMQ in this “evolution.” AMQ was probably always a quack, or at least started the pandemic as a quack. (After all, this is someone who unironically cited Mike Adams’ old music video Vaccine Zombie as being frighteningly prescient and argued a couple of years ago that smallpox vaccines were not responsible for the elimination of smallpox.) Strike that. AMQ was always a quack:
Before becoming a doctor, I trained and worked in the holistic medical field and was immensely bothered by how much marketing and self-promotion were necessary to succeed in that industry (even if you got great results for your patients). One of the reasons I ultimately went to medical school was so that I would not need to market for the rest of my life (any decent doctor who breaks from the medical orthodoxy will always have a patient base). So, throughout my career, I’ve followed the philosophy that if you focus on the quality of your work, everything else will work itself out (I’ve also been fortunate to train under some remarkably talented and highly successful physicians, each of whom also refused to market or promote their practice).
But back to statins.
Skepticism about the role of cholesterol in the pathogenesis of heart disease has existed for a long time, and there was a time decades ago when that skepticism was based in science. I’ll explain in a minute. First, let’s look at what AMQ says:
However, despite a significant amount of data that now shows lowering cholesterol is not associated with a reduction in heart disease (e.g., this study, this study, this study, this review, this review, and this review) the need to lower cholesterol is still a dogma within cardiology. For example, how many of you have heard of this 1986 study which was published in the Lancet, which concluded:
During 10 years of follow-up from Dec 1, 1986, to Oct 1, 1996, a total of 642 participants died. Each 1 mmol/L increase in total cholesterol corresponded to a 15% decrease in mortality (risk ratio 0–85 [95% Cl 0·79–0·91]).
Wow! Sounds damning, doesn’t it? Of course, notice that most of these studies are from last century, and the ones that aren’t either don’t support the conclusions that AMQ is using them to support or were carefully cherry picked. For example, this study looked at statins in the “oldest of the old” and concluded that in people 85 years old and older, high total cholesterol concentrations are “associated with longevity owing to lower mortality from cancer and infection,” a special subset. (The study is also from 1997.) This article only argues that data didn’t support 1983 UK dietary guidelines for lowering fat and cholesterol. OK, that was 40 years ago! Another study was done as a followup to the Seven Country Study and noted that age-adjusted “CHD mortality continuously declined between 1980 and 2007 in all these countries, but that the “decline was accompanied by a constant fall in total cholesterol except Japan where total cholesterol continuously rose.” In other words, the point of the article was: What’s different about Japan? It wasn’t a claim that lowering cholesterol doesn’t decrease the risk of heart disease!
You get the idea. As documented extensively, statin/cholesterol denial has gone from reasonable skepticism over three decades ago to become dangerous pseudoscience.
Why are the age of the other studies important? Simple. Statins, which lower cholesterol levels, were not widely introduced until the 1990s. Before that, there were two strategies to lower cholesterol levels: diet or drugs that didn’t work very well and were often poorly tolerated. Cardiologist Dr. Christopher Labos recently published a pretty comprehensive article on anti-statin quackery, How cholesterol denialism went from reasonable skepticism to pseudoscience, and described the situation as it existed at the end of the 1980s:
And so we come to the inflection point and the Atlantic cover of 1989. “Lowering your cholesterol is next to impossible with diet, and often dangerous with drugs – and it won’t make you live longer.” It was technically correct. But for the first time you had a divergence in the debate. You could argue that the current medications were not effective at changing outcomes, and in retrospect they weren’t. They were terrible by modern standards. But if you look back objectively at the history of the research, it was pretty clear that cholesterol was involved in the process of atherosclerosis. Every time you lowered it significantly, people had fewer heart attacks. We just lacked the tools to make a major dent in people’s serum lipid profile.
In the 1990s, everything changed. Statins entered the market and the 4S study with simvastatin showed that the medication lowered cholesterol, reduced heart attacks, and also reduced cardiovascular and all-cause mortality. Twenty-six randomised studies later, it became clear that statins did what they promised.
Dr. Labos was citing a 2010 meta-analysis of 26 randomized controlled trials published in the Lancet, which conclude:
Further reductions in LDL cholesterol safely produce definite further reductions in the incidence of heart attack, of revascularisation, and of ischaemic stroke, with each 1·0 mmol/L reduction reducing the annual rate of these major vascular events by just over a fifth. There was no evidence of any threshold within the cholesterol range studied, suggesting that reduction of LDL cholesterol by 2-3 mmol/L would reduce risk by about 40-50%.
That’s a pretty solid result.
I also learned something new, namely that AMQ was engaging in another favored tactic of quacks and focusing on one investigator whose work had problems and ignoring all the other contemporaneous data being generated. In this case, AMQ focuses on Ancel Keys, whose Seven Country Study represented some of the earliest research that supported a link between cholesterol levels and cardiovascular disease, reporting 30-fold cohort differences in rates of death from coronary heart disease and 3-fold differences in rates of death from all causes, along with strong ecologic associations among diet, risk factors, and disease rates. AMQ claims, without citing a source, that:
However, what many don’t know (as this study is still frequently cited) is that this result was simply a product of the countries Keys chose (e.g., one author illustrated that if Finland, Israel, Netherlands, Germany, Switzerland, France, and Sweden had been chosen, the opposite would have been found).
Dr. Labos points out, however, that the focus on Keys, however flawed his study might have been, ignores all the other evidence at the time pointing to cholesterol as contributory to heart disease:
Fast forward to the 1940s and 1950s and researchers were trying to determine what could be done about the skyrocketing rates of heart disease in the early 20th century. This was the time of the Seven Countries Study by Ancel Keys, which has become a lightning rod for arguments in recent years, largely because of books like “The Big Fat Surprise” and others. Others have pointed out issues with the many criticisms levelled at Keys’ work. Broadly, we can make two points. First, the Seven Countries study was not the only study published on the subject. The Framingham Heart Study also drew associations between cholesterol and heart disease, so focusing solely on Keys essentially ignores all the other large contemporary studies of the time. Secondly, these large studies were about identifying risk factors for heart disease.
An important caveat, though, is that these weren’t diet studies or randomised trials. If you want to see whether lowering cholesterol reduces heart disease, you have to design a trial that lowered cholesterol and measured hard clinical endpoints. Had you been alive at the time, you might have said the same.
I can’t help but note that the link in the “criticisms leveled at Keys’ work” goes to a criticism whose corresponding author was Dr. David Katz. You might recall him as the the “integrative” medicine doctor who infamously said that he had “arrived at the use of a more fluid concept of evidence than many of us have imbibed from our medical educations.” Still, there are a number of valid criticisms of Keys’ work; it’s just that Keys’ work, contrary to how quacks portray it, was never the be-all and end-all of 20th century research into the associations between dietary fats and cholesterol and risk of heart disease. It is also true that the studies before statins were conflicting regarding whether decreasing cholesterol levels also decreased the risk of heart disease, which is why that Atlantic article from 1989 was not as unreasonable in the context of when it was published as it comes across now. The state of the science was somewhat conflicting, and although studies of the drugs that existed at the time, on clofibrate and cholestyramine, did show that lowering cholesterol also lowered the risk of cardiovascular events, the drugs were poorly tolerated.
So, as Dr. Labos showed above, it’s true that the science regarding statin drugs was conflicted…in the 1980s and into the 1990s. It has not been conflicted for nearly three decades, however, since the 4S study was published in 1994. It’s not just statins, either. One criticism was that the reduction in risk of heart disease was something somehow unique to statin drugs. However we now have other drug classes other than statins that lower cholesterol, and guess what? They work too:
As long as statins were the only useful cholesterol medications available, you could maybe convince yourself the benefits were unique to that drug class. But they aren’t the only medication out there anymore. The development of ezetimibe (which blocks cholesterol absorption in the intestine) and PCSK9 inhibitors (which act on the cholesterol receptor in cells) have made that argument unsustainable.
The amazing thing about cholesterol medication is that their benefit is very linear. If you plot out all the studies of cholesterol medications (both statin and non-statin treatments), they fall along a very straight line. The point is a medication’s cardiovascular benefit is proportional to how much it lowers cholesterol. Dietary interventions have a small impact whereas the newer injectable cholesterol medications called PCSK9s have a huge cardiovascular risk reduction. In the end, there’s nothing special about statins. It’s the degree of cholesterol lowering that matters.
Indeed it is. All that leaves AMQ, whose work Dr. Kory seems to admire so, two things: hyping “harms” from statins and, of course, conspiracy mongering. AMQ expends what appears to be more verbiage on conspiracy mongering about big pharma supposedly banding together to fake data and promote statins than on actual evidence, all likening it to big pharma doing the same thing for COVID-19 vaccines, probably to keep it relevant for the core audience of COVID-19 conspiracy theorists.
Here’s just a taste:
Note: one of the most unfair things about statins is that the healthcare system decided they are “essential” for your health, so doctors who don’t push them are financially penalized, and likewise patients who don’t take them are as well (e.g., through life insurance premiums).
So, despite the overwhelming evidence against their use, many physicians believe so deeply in the “profound” benefits of statins that they do things like periodically advocating for statins to be added to the drinking water supply.
In tandem, a cancel culture has been created where anyone who challenges the use of Statins is immediately labeled as a “statin denier” accused of being a mass murderer and effectively canceled. Recently, one of those dissidents, Dr. Aseem Malhotra British cardiologist who has also spoken out against the COVID vaccines went on Joe Rogan where he discussed that dirty industry and the remarkable parallels between how Statins and the COVID vaccines were pushed on the world:
I forgot to mention. Like all conspiracy mongering, statin denial claims that its brave maverick doctors are being “canceled” for daring to speak The Truth. Also, citing Dr. Aseem Malhotra? He’s the cardiologist who made his first pandemic quack splash in 2020 by claiming that “metabolic optimization” would save you from the coronavirus. Now, he’s just seriously antivax; so of course he’s a statin quack too.
Antivaxxers frequently make the same claim about vaccines, given that insurance companies do pay, for example, pediatrics practices bonuses for maintaining a certain percentage of their patients up to date on CDC-recommended vaccines. Antivaxxers see this as a conspiracy, collusion between big pharma and the insurance companies. In reality it’s insurance companies making a cold, hard, data-driven calculation that they will pay out less for patients who are up to date on their vaccines because paying for vaccines is much less expensive than paying for treating the diseases prevented by the vaccines. The same calculation goes into insurance companies promoting statins. Most statins are off-patent now and available as inexpensive generics. Insurance companies no doubt view it as much less expensive to pay for patients’ statin drugs than to pay the bills for more hospitalizations for cardiovascular disease complications. It really is that simple,
The other thing AMQ has left is to fear monger about exaggerated risk of complications from statins. To get an idea of the flavor of this fear mongering, let me just cite this:
In addition to cognitive impairment, numerous studies have found a significant association between low or lowered cholesterol levels and violence. Likewise, statin dementia is often characterized by aggression.
Finally, one of the most concerning side effects of statins is their tendency to cause ALS (a truly horrible rare disease—curiously also seen in association with the COVID-19 vaccines). This correlation is further supported by many reports of statin ALS improving once the statin is stopped.
Notice first, how AMQ does not cite any literature to support his claim that statins can cause ALS. This is a common theme in AMQ’s articles. Sometimes peer-reviewed papers are cited (usually cherry picked); sometimes claims are made without support. Also note how the “numerous studies” is one 1998 review that didn’t even look at statins, but rather between cholesterol levels and violence. Can you say “cherry picking”? Sure, I knew you could. It’s not as though there aren’t studies that failed to find a correlation between statin therapy and aggression, such as this 2018 study, although lower total cholesterol levels were associated with aggression and this 2000 study that found no affect on well-being due to long-term statin therapy. In fairness, there does seem to be a fair amount of literature that suggests that lower cholesterol levels is associated with agitation, but people who already have lower cholesterol levels are not going to be treated with statins, and there isn’t any good literature. AMQ does cite one study, but its results were mixed, with statins being associated with aggression in females but lower aggression in males. Moreover, studies he cites point out that psychiatric complications from statins tend to be rare events.
Unsurprisingly, AMQ also cites the known problems with statins, such as muscle pain and autoimmune muscle damage. These are well-known and uncommon. In patients who need statins, the risk benefit profile of the drugs is quite favorable.
Also, let me cite Dr. Labos, who puts this into perspective:
You will hear people argue that statins are too expensive, that the benefits are too marginal in a general low risk population, or that they don’t want to endure the side effects. It’s worth pointing out that statins are now off-patent, and no pharmaceutical company is lobbying for their use. The benefits of statins are inherently higher in high-risk populations and lower in low-risk ones. All medications work this way. But even in patients without cardiovascular disease, there is a cardiovascular benefit. It just isn’t as marked as what you see in patients who have a history of heart attack or stroke.
Correct. Chemotherapy after surgery can have benefits in even low-risk cancers; it’s just that the benefits are much smaller than in cancers at high risk of recurrence, which is why chemotherapy is often not recommended for these low-risk cancers that have been successfully resected.
Moreover:
You can argue that there are better ways to measure cholesterol beyond the simple characterization of good (HDL) cholesterol versus bad (LDL) cholesterol. You can argue that, in low-risk populations, the cost of therapy outweighs the benefit. You can argue that we should be doing more to encourage lifestyle change and healthy eating habits, especially among children. All of these are interesting arguments, but they are questions of policy, not science.
All of these are not unreasonable arguments, and, in fact, it’s fairly accepted that in low risk populations statins are probably not indicated. This is not, however, what quacks like Dr. Kory and AMQ are arguing. They are arguing that statins are an evil plot by big pharma to make money, that they help no one and harm many, that “They” are “canceling” brave maverick doctors who speak The Truth about statins. The anti-statin cult is based on conspiracy theories, not science. No wonder quacks like Dr. Kory and AMQ are so drawn to it.
I conclude by harkening back to the concept of “crank magnetism,” first proposed by Mark Hoofnagle way back in 2007 to describe the tendency of a crank who falls for one form of pseudoscience or quackery to start falling for others. with a comment about how “cranks are magnetically attracted to other crank arguments.” If there’s one thing that the pandemic has emphasized yet again, it’s that crank magnetism is real, although I would add my own corollary: It’s the conspiracy theories. I’ve argued that all science denial is conspiracy theory at its heart, which is why an attraction to one conspiracy theory generally implies an attraction to many conspiracy theories, with denial of one form of science leading to susceptibility to denial of other forms of science. Dr. Kory and AMQ are poster children for this phenomenon.
2 replies on “Dr. Pierre Kory has gone all-in on anti-statin quackery”
There’s actually evidence that statin use lowers risk of Alzheimer’s disease. For example, a Swedish registry study of ~15 thousand patients (Petek et al 2023 AlzRes&Ther) found better MMSE scores for patients using statins over 3 years, with higher doses producing better effects.
Another example of vaccine denial and cardiac health denial. Weston Price Foundation doesn’t believe viruses exist (and therefore vaccinations are unnecessary) and also claims eating lots of meat is necessary. I don’t know their views on statins but I doubt they’re supportive. (I take atorvastatin, personally.)