The JUPITER Trial

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

We now have this and most other articles published in the Parkland Shopper on our Website. Please visit us at www.dcp.ca

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

Back on November 20, 2008 we got to go to a very interesting talk sponsored by the pharmaceutical company AstraZeneca. It was a teleconference going on live across Canada at the same time. There were over 1200 family physicians (and a few pharmacists) listening to some very bright researchers out of Toronto talk about the JUPITER Trial.

The trial talked about a choleterol pill called crestor or rosuvastatin helping people reduce their hsCRP which means there is less inflammation in their blood vessels. None of that made any sense to you? No problem, let’s go through some background information.

Cholesterol medications called statins or HMG-CoA reductase inhibitors are very commonly used. They work very well at reducing cholesterol, especially LDL or bad cholesterol. Researchers have found over time that if we reduce a person’s LDL, they will be less likely to have a heart attack or stroke. So we put people on statins to reduce their chances of heart attacks or stroke.

Not surprisingly, it is not as simple as reduce cholesterol and you reduce the chance of heart attacks and stroke. Nothing with the body is ever that simple. There are people with high cholesterol who don’t have heart attacks and stroke. There are people with low cholesterol who do have heart attacks and stroke. There are even people with actual cholesterol laden partial blockages in their arteries (called plaques) that don’t go on to have a heart attack or stroke. It is only when these plaques become “unstable” that we get problems. The other thing that is going on may be inflammation in the blood vessels and statins might help that too.

We have known for a while that statins do other good things for preventing heart attacks and stroke than just lowering cholesterol. There have been studies that showed with the medication lipitor or atorvastatin there were benefits to reducing heart attack or stroke over and above how much the atorvastatin reduced the cholesterol. So was this because the atorvastatin reduced inflammation in the blood vessels?

This brings us to the JUPITER trial. They used the cholesterol pill rosuvastatin and measured both the LDL and the hsCRP. High sensitivity c-reactive protein (hsCRP) is a measurement of inflammation. One of the ways to look at people in general is to put them in 4 groups
Low LDL, low hsCRP – these people have very few heart problems. They weren’t in the trial.
Low LDL, high hsCRP – this is an interesting group. We wouldn’t normally give these people a statin, because their cholesterol isn’t high. But, this is the group that went into the JUPITER trial. They did give these people rosuvastatin and their hsCRP’s went down.
High LDL, low hsCRP - not in trial. We already know from previous trials that if we give these people a statin they will have less heart problems.
High LDL, high hsCRP - not in trial. We already know from previous trials that if we give these people a statin they will have less heart problems.

So the people in the JUPITER trial with low LDL and high hsCRP had their hsCRP go down with rosuvastatin. This means the inflammation in their blood vessels went down with rosuvastatin. They also had fewer heart problems with rosuvastatin. So reducing hsCRP with statins reduces heart problems, right? Maybe.

Dr. Hrabarchuk gave us a good commentary after the presentation in Dauphin and I have read some other people’s thoughts since about how good the JUPITER trial was. There are some criticisms.
The trial itself was well done, but the improvement is very small. Pharmacist’s letter did the math and to prevent one hard cardiac endpoint (heart attack, stroke or cardiovascular death) you would need to treat 120 people for 1.9 years. That is a lot of people buying and taking a lot of pills to prevent one event.
The hsCRP test is not free. It costs ~$70. Is it worth the money?
Are the good benefits, however small, from lowering LDL or lowering hsCRP or both?
Can we lower hsCRP (and inflammation) by a cheaper method like a low dose ASA?

So should everyone run out and get an hsCRP and then demand their docs lower them with rosuvastatin? Probably not. JUPITER was a very good trial, and had some interesting results, but hsCRP and heart problems needs more study. What is not under debate is that if you have high LDL you should be on a statin. It has been estimated that only about half the people prescribed a statin are still on it six months later. That is definitely bad for their health.

As always if you have any questions or concerns about these products, ask your pharmacist.