By Larry Kaskel, MD

I am an internist and, once upon a time, a card-carrying lipidologist. I have spent years watching medicine’s “standards of care” quietly stretch like elastic waistbands. What begins as a targeted therapy for a small group of high-risk patients slowly expands until everyone and their grandmother is expected to be on it. That phenomenon has a name: guideline creep.

How it works

The cycle is simple:

- A landmark trial shows benefit in a high-risk population.

- The results are reported as impressive relative risk reductions.

- Guideline committees, often with pharmaceutical “input,” generalize the findings.

- Over time, optional becomes recommended, recommended becomes standard, and eventually, you are considered negligent if you do not apply it to everyone.

- Guideline creep is medicine’s version of “mission creep.” Once you notice it, you see it everywhere.

Case study: Atrial fibrillation

The first AF trials of warfarin enrolled older patients with prior strokes or multiple risk factors. The absolute risk reduction (ARR) was real: 4 to 6 percent fewer strokes per year, with an NNT of approximately 20.

Fast-forward three decades. With DOAC marketing in full swing and CHA₂DS₂-VASc scores as our guide, virtually every AF patient, down to the 65-year-old with controlled hypertension, is told to anticoagulate. In these low-risk cases, ARR is closer to 0.5 percent per year, NNT >200. That is a long way from the original evidence.

Statins: From sick to well

The Scandinavian Simvastatin Survival Study (4S, 1994) saved lives, no question. Men with prior MI, LDL sky-high, smoking like chimneys. ARR was 4 to 5 percent over five years.

But now? Guidelines have crept so far that a healthy woman with borderline cholesterol and a 10-year ASCVD risk of 5 percent is nudged toward a lifelong prescription. Here the ARR is <1 percent over a decade, but the “standard of care” box still gets checked.

Blood pressure and diabetes

We have done the same with hypertension (lowering the threshold to 130/80 overnight created millions of new “patients”) and diabetes (rebranding healthy people as “prediabetic”). Each shift means more prescriptions, more monitoring, more fear.

Why it happens

- Relative risk framing hides how small the real benefit is.

- Pharma sponsorship ensures guidelines align with what can be billed and sold.

- Defensive medicine makes clinicians afraid to be out of step.

- EMRs and quality metrics hard-wire the broadest interpretation of guidelines.

The cost

Guideline creep medicalizes the well, overtreats the low-risk, and siphons resources away from interventions that actually move the needle: diet, activity, and the infectious roots of chronic disease. It is the slow erosion of common sense in the name of “standard of care.”

My confession

As a “lipidologist in recovery,” I will admit I played along. I gave talks for drug companies, quoted relative risk reductions, and nodded at guideline slides that looked scientific but were quietly expanding their reach. It took me years, and the collapse of the HDL hypothesis, to realize how much creep had seeped into my own practice.

Closing line

Guideline creep is not evidence-based medicine. It is evidence-stretched medicine.

Larry Kaskel is an internist and “lipidologist in recovery” who has been practicing medicine for more than thirty-five years. He operates a concierge practice in the Chicago area and serves on the teaching faculty at the Northwestern University Feinberg School of Medicine. In addition, he is affiliated with Northwestern Lake Forest Hospital.