10 truths about statins and high cholesterol

February 2, 2016
or every drop of scientific evidence that statins are safe and effective, there is a tidal wave
of misinformation. Our patients are concerned about statin side effects they’ve heard
about from family or friends, or read about on the Internet.

Statins are the “gold-standard” for high cholesterol treatment. They’re a powerful
medication, and they’ve been proven to save the lives of many men and women living
with or having a high risk of heart attack or stroke.

But if statins are so effective, why are some people afraid to take them?

As with any medication, there are risks associated with taking statins, but the benefits far
outweigh the risks for the vast majority of high-risk patients.

In an effort to put statin side effects into context and provide honest, scientific answers
about statins and their use, we’ve put together a list of common questions our patients
ask us:

How are doctors sure that statins really are safe and beneficial?

Statins have been studied more than nearly any other drug that people take. In fact,
more than 170,000 people who take statins have been studied in detail and for
extended periods of time. We certainly know the benefits of statins.

We also understand the risks of statins. In some instances, after doctors have
prescribed a drug for 10 years or more, it is taken off the market because of unforeseen,
adverse side effects. We’ve been prescribing statins since the 1990s for patients at high
risk for stroke and heart disease. With statins, the side effects actually are well
known. But how can we put that in perspective?

Any focus on statin side effects needs to be counterbalanced by the fact that statins
reduce people’s risk of dying from heart attack, heart disease, or stroke. Data from the
2008 JUPITER Trial suggest a 54 percent heart attack risk reduction and a 48 percent
stroke risk reduction in people at risk for heart disease who used statins as preventive
medicine. The data are not speculative; rather, they reflect statins’ real potential to
save lives and avoid illness.

There are many varieties of brand name and generic statins available. All statins work in
more or less the same way to lower bad cholesterol (LDL cholesterol) in patients at high
risk for cardiac events.

Below are a few of the common brand names you may recognize, along with their
generic counterparts:

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  Lipitor (atorvastatin)
 Crestor (rosuvastatin)
 Mevacor (lovastatin)
 Lescol (fluvastatin)
 Pravachol (pravastatin)
 Zocor (simvastatin)
 Livalo (pitavastatin)
 Vytorin (simvastatin/ezetimibe)
How do doctors decide who is prescribed a statin?

In preventive cardiology, it’s up to us to help patients avoid suffering from a sudden,

serious cardiovascular event, such as a heart attack or stroke, or a long, grueling
ailment such as atherosclerosis (hardening of the arteries). We determine on an
individual basis which patients have the greatest need and who would benefit most from
taking statins. We weigh these benefits against the known risks for each patient before
we consider prescribing the medication.

Like all medications with risks and benefits, there are specific guidelines we
follow to ensure that we prescribe statins only to people who really need them.

The American College of Cardiology and American Heart Association developed these
rational guidelines in 2013 after carefully reviewing the decades of published studies
about statins. First, we determine a patient’s overall risk of cardiac disease, taking into
account their cholesterol levels as well as other risk factors such as blood pressure,
smoking history, diabetes, age, and sex.

There are four general categories recommended to determine who is at high risk for a
cardiovascular event, such as a heart attack or stroke.

The guidelines recommend statins for adults who:

 Have clinical atherosclerotic cardiovascular disease (ASCVD), including those

with a personal history of stroke, heart attack, or peripheral vascular disease,
and also those who suffer from chest pains (angina)
 Have high cholesterol (an LDL cholesterol of 190mg/dL or higher)
 Are age 40 to 75 and have diabetes
 Are age 40 to 75 and have an estimated 10-year risk of an ASCVD event
greater than 7.5 percent
We know that statins can be used to protect against more than heart attack – statins
also protect against stroke in high-risk patients. A stroke is caused by blocked blood

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flow to the brain, and high cholesterol is one of the culprits for such blockages. In high-
risk patients, statins have been shown to decrease the risk of stroke by decreasing
patients’ cholesterol.

We may recommend statins for other people, even if they don’t fit in these
categories. For example, if a close relative has suffered a heart attack and your own
cholesterol levels are getting higher regardless of lifestyle improvements, we may
recommend that you take a statin.

Importantly, we consider cholesterol treatment as one piece of the overall puzzle of

lowering risk. For example, it does little good to lower a patient’s cholesterol with a
statin but ignore his or her high blood pressure. A comprehensive approach to risk
factor management, including lifestyle factors such as diet and exercise, is most
effective.
Do statins cause muscle pain and weakness?

Muscle aches occur in about 10 percent of people who take statins. It’s the most
common side effect of statins, but another way to look at it is that nine out of 10
patients don’t experience it at all.

When patients do have muscle pain:

 The symptom is often resolved by adjusting the medication dosage or switching

to a different statin.
 Occasionally, the statins have to be stopped altogether.
 When the medication is switched or stopped, the symptoms go away and there
is no damage to the muscle.
Actual muscle damage occurs in only 1 in 10,000 patients. In the rare event that muscle
damage occurs, it is almost always reversible. To correct it while still protecting you
from heart attack or stroke, we can adjust your medication or try a different statin. There
also are many strategies to effectively manage muscle symptoms while continuing to
take your medication.

If you experience muscle pain while taking a statin, don’t stop taking it without first
talking with your doctor. For almost all patients, we’re able to find an effective
medication that the body can tolerate. If you simply can’t tolerate statins, there are
other cholesterol medications we can prescribe.

Can statins increase my risk for memory loss or dementia?

Memory and cognitive symptoms from statin use are very uncommon, and it is unclear if
statins are really the culprit. When symptoms have been reported, they’re typically not
severe and usually resolve when the statin dosage is adjusted or the medication is

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switched.

Affected patients have reported feeling unfocused or “fuzzy” in their thinking, but these
experiences are rare. Concerns about long-term cognitive problems and memory loss
due to use of statins have not been proven. On the contrary, most recent data actually
point to potential prevention of dementia due to statin use.

These data are logical because one of the major causes of dementia is atherosclerosis,
which is hardening of the arteries in the brain. There is strong evidence that statins
protect against atherosclerosis. It’s one of the “invisible” benefits of taking a statin
medication.

Also, keep in mind that increasingly high cholesterol (requiring treatment) and memory
problems both are common symptoms of aging. Sometimes it’s difficult to disentangle
these two, and that’s why statin use and memory problems may seem related at times.

If you’re concerned about statins and memory loss, don’t stop taking your
medication without consulting your doctor. There may be other reasons for your
memory symptoms, or alternate treatments for your high cholesterol can be considered.

Will statins increase my risk for diabetes or complicate my existing diabetes?

This risk is true to some extent, but it’s wildly exaggerated.

 If your blood sugar was under control before you began taking statins,
your sugars may rise slightly. But if you’re slim, trim, and not predisposed to
diabetes because of obesity, statins won’t cause you to develop diabetes.
 If you already had prediabetes or have borderline blood sugar levels, the
statin may make your blood sugar rise enough to put you in the diabetes
category. This happens to about one of every 255 patients taking statins. When
it does happen, the patient is already on the path to getting diabetes – it just
happens a little faster. In these patients, statin use simply accelerates by a few
weeks to a few months a condition that was already inevitable over their
lifetime.
 Statins slightly increase the incidence of Type 2 diabetes in people who
have two or more symptoms of metabolic syndrome, but the benefits of
statins for these patients generally far exceed the risk of elevated blood
sugar.
In fact, there are good data to show that people who have problems with their blood
sugar or who have diabetes benefit most from statins. Even though their blood sugar
may go up slightly, the added risk is significantly offset by the reduction in heart disease
risk that a statin can provide.

If you’re already at risk for developing Type 2 diabetes, or if you have prediabetes, you

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may monitor your blood glucose more closely after starting a statin. But exercise and
weight loss have been shown to lower the risk of developing diabetes in those with
borderline blood glucose levels, regardless of statin use.

Can statins damage my liver?

Liver damage from taking statins is extremely uncommon. We used to test patients for
liver damage throughout the course of statin treatment, but because of the rarity of that
potential side effect, the Food and Drug Administration (FDA) determined that regular
monitoring of liver function tests is unnecessary for patients taking statins. Now, we
check a patient’s liver enzymes before we begin statin therapy to ensure the liver is
healthy before treatment begins, and we don’t put anyone through unnecessary testing
during treatment, unless symptoms arise.

Interestingly, there is a statin study examining people who already had abnormal liver
function tests and fatty liver. Roughly half of the participants took a statin medication,
and the other half took a placebo. The people who took statins actually had
improvements in their liver function compared to the placebo group and had a
lower risk of cardiovascular events. People who have blood sugar issues, have
insulin resistance, and are obese or have other risks for heart disease often have fatty
liver and abnormal liver function tests. The study suggests that these people may need
statins the most.

On the rare chance that symptoms of liver damage arise, we’ll definitely want to perform
tests right away. Symptoms of liver damage include weakness and fatigue, loss of
appetite, upper abdominal pain, dark-colored urine, or yellowing of the eyes or skin.
Again, it’s very rare, but if you experience any of these symptoms while taking a statin
medication, contact your doctor right away.

Do statins cause cancer?

There is no evidence to suggest that taking statins increases cancer risk. Several studies
suggest possible benefits for patients who take statins and are currently fighting
cancer; research is ongoing as to whether statins actually may help prevent cancer.

Why do doctors focus on my LDL cholesterol?

Some cholesterol is necessary for normal cell and body function. But too much
cholesterol can lead to atherosclerosis (hardening of the arteries), which results in heart
disease, heart attack, and stroke.

There are two types of cholesterol: high-density lipoprotein (HDL, or good cholesterol)
and low-density lipoprotein (LDL, or bad cholesterol). The amount of each that
circulates in your blood is added together to form your total cholesterol number. Thus,
focus on total cholesterol can be confusing as it may be elevated due to high HDL

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cholesterol.

When your LDL cholesterol is above 130 it is considered borderline, while above 160 is
considered high. Ideally, we would all have an LDL under 100 (or even closer to 70), but
not everyone needs medications above this level.

We focus on the bad cholesterol because it is one of the main culprits

responsible for blocking and hardening the arteries. A blocked artery can lead to a
heart attack or stroke. Statin therapy helps control the bad cholesterol of patients who
are at high risk for heart disease, stroke, and other serious cardiovascular events. In
general, the lower your LDL levels, the better off you will be.

There’s a lot of science around how HDL cholesterol affects your risk for heart
disease. But it’s the function – how well it works – that may be more important
than how high its level is.

For example, people in a small village in Italy have very low HDL numbers (10 to
30mg/dL), and they have a longer life expectancy and very little heart disease. That’s
because their HDL is like a factory – it shuttles cholesterol from the arteries to the liver
rapidly, and then disappears. Good cholesterol doesn’t last in their blood very long, but
it is very efficient.

Society’s focus on raising HDL is likely misguided when compared to the actual
evidence. Two recent studies of raising HDL with niacin showed no improvement in risk
of heart attacks and strokes, and potentially some harms. There is a lot of work to be
done to determine what we can and should do in targeting HDL.

Can ‘natural’ remedies lower high cholesterol without

statins?
Exercise on its own doesn’t lower your LDL (bad cholesterol) much – often only a few
points. Exercise helps minimize many heart disease risk factors, including obesity
and Type 2 diabetes. Make a point to exercise five days a week for at least 30 minutes
each day.

Diet is incredibly important in managing your cholesterol.

 Certain foods, such as fried food and fast food, are high in saturated fat, which
contributes to high cholesterol.
 Not all fats are unhealthy – good fats, such as those found in fatty fish, nuts,
and olive oil, have many health benefits.
 Read food labels and limit your daily intake of saturated fat to 16 grams, and
omit trans fats completely.

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  Eating more fiber can help reduce LDL significantly. For some patients, eating
fiber along with maintaining an exercise program is enough to manage
cholesterol. But for high-risk patients, it’s not enough to prevent the need for
statins.
Every patient who comes to our preventive cardiology clinic for cholesterol management
sees a nutritionist as part of the visit because we feel so strongly about the importance
of diet. There are many patients for whom we’ve delayed prescribing statins, or
suggested that they get off their medication if it isn’t appropriate for their level of risk.

Some patients think, “I’m on a statin – I don’t have to exercise, and I can eat whatever I
want!” But that’s not the case. Lifestyle choices absolutely matter. For high-risk
patients, it’s not a question of either improving the diet or getting on a
medication, it’s both – lifestyle changes and taking a statin together are necessary to
protect high-risk patients against heart attack and stroke.

If your cholesterol is borderline but not yet high, changing your diet and incorporating
healthier food choices can help lower your cholesterol a decent amount. Eating more
fiber and lowering your intake of saturated fat definitely can help. For people with
relatively low risk, this may be enough to lower heart attack and stroke risk.

Are there alternatives to statins for lowering high cholesterol?

In patients whose cholesterol can’t be controlled by lifestyle changes or who simply can’t
tolerate statins, we can offer alternative treatments.

Bile Acid Binding Resins

For example, the FDA has approved a class of drugs known as bile acid binding resins,
which were the first cholesterol drugs before statins. Studies in the 1980s showed that
these medications lower heart disease risk. One reason they aren’t often prescribed is
that patients have to take a lot of them compared to statins. Bile acid binding resins come
in powder form or require taking up to six pills a day. Also, they can cause gastrointestinal
side effects.

We’ve known since the 1990s that statins benefit patients at high risk for stroke and heart
disease. Today, several investigators are researching which complementary medications
can be prescribed on top of statins to make them even more beneficial and protective.

One of these is a drug called Ezetimibe, which on its own provides a modest reduction in
cholesterol. It’s also been shown recently to lower heart attack and stroke risk when taken
in addition to a statin.

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PCSK9 Inhibitors

There are other non-statin cholesterol medicines, too, but the same principles apply –
they should be used only for high-risk patients, and the risks must be weighed against the
benefits.

In 2015, the FDA approved two new drugs that target and inhibit the PCSK9 protein,
which affects the levels of bad cholesterol. The two drugs, Repatha and Praluent, block
or reduce PCSK9 activity in order to lower LDL cholesterol by more than 50 percent and
potentially reduce cardiovascular risk. These drugs are not pills; they are taken via
monthly or twice-monthly injections. Outcomes data for PCSK9-inhibiting drugs are not
yet available, but we are looking forward to seeing those results within the next few years.
Currently, these drugs are FDA approved for those with ASCVD or those with a genetic
cholesterol problem called familial hypercholesterolemia whose cholesterol levels are not
controlled enough by a statin.