Introduction

 

Do you or someone you know take a cholesterol-lowering medication called a Statin like Atorvastatin, Lovastatin, Simvastatin, or Rosuvastatin?

 

It’s a great drug, right? Right?

 

I’m sure a lot of doctors would think so… and you can tell.

 

Lipitor, which is also called Atorvastatin, is America’s most prescribed drug. 

 

They’re shown to be potentially life-saving because they can help break up potential clots caused by a buildup of cholesterol which in turn, prevents heart attacks, DVTs, Pulmonary Embolisms, Stroke.

 

It’s not without controversy though. even among doctors themselves which is what we’re going to talk about today. 

 

But first, the controversy can’t fully be appreciated before understanding the basics. So let’s start with:

 

What Are Statins?

 

Statins… is a class of medication that is designed to lower cholesterol and it does this by inhibiting an enzyme called HMG-CoA Reductase which is what your body uses to make cholesterol. So we’re preventing it from being made.

 

Usually, when we talk about cholesterol… it’s usually referred to negatively.

 

And that’s because too much of a specific cholesterol called LDL (or Low-Density Lipids) can build up in the walls of your arteries which is a condition called atherosclerosis. 

 

With this build up in your blood tubes, your blood pipes would naturally become more narrow. This makes it a lot less efficient at transporting blood around your body, and significantly increases your risk of heart attack and stroke because it’s much easier to cause a blood clot in an already narrow tube.

 

Statins are also used for other things as well.

For instance, they’re recommended for diabetics.. It actually doesn’t control blood sugar but there’s studies that show that diabetics simply live longer when they’re on a statin.

 

Now the way a doctor would decide whether you get statin if you’re a diabetic is with an online calculator that uses your age, your history of heart attack and stroke and some other health habits like smoking. The calculator, from my own personal use, gives very non-intuitive conclusions.

 

I remember putting my own health metrics in like 10 years ago, I was still in my late 20s, I don’t smoke, and it said I would be qualified for a statin if I was a diabetic. Now the calculator has definitely been updated since but I know that there’s still some debate over how helpful the calculator actually is.

 

There are lots of different statins available, each one with different levels of effectiveness or different levels of cholesterol lowering.

 

We have Simvastatin, which is in general a low-intensity statin.

 

We have Lovastatin, also considered a low-intensity statin. Fun fact with this one, red yeast rice, which can be purchased over-the-counter has a compound in it called monacolin K that is chemically identical to Lovastatin so it’s possible to lower cholesterol with an over-the-counter product.

 

We also have Atorvastatin which goes by brand name Lipitor which we talked about, and is the highest selling drug of all time. This one is a medium to high intensity statin at its largest dose.

 

And then we have the newest mainstream player which is Rosuvastatin which goes by brand name Crestor and this one is considered a high-intensity statin.

 

And these high intensity statins are almost always given to patients who’ve just had like a heart attack or stroke to prevent a blood clot from happening again because once you’ve had one blood clot, you’re statistically more likely to have another and, we don’t want that.

 

Side Effects

 

Now most, if not all medicine is not without consequence.

 

Statins do have side effects that are definitely a cause for concern for some patients and healthcare providers.

 

The first side effect we usually talk to patients about is muscle pain and weakness. Some people might describe this as soreness or tiredness and be anything from a mild discomfort to more severe pain that might interfere with daily activities.

 

In the rarest cases, sometimes when we use it with other medicines, statins can cause severe muscle damage called rhabdomyolysis, sometimes we just call this rhabdo and this involves severe muscle breakdown and can potentially all cause kidney damage, because those bits and pieces of muscle called myoglobin get stuck in the kidneys and solidify as the kidneys are trying to do their job and filter it out.

 

We also worry about liver enzymes sometimes. Levels can sometimes go up which might be a sign of liver damage or liver inflammation. Levels are usually easily reversed though if you simply stop the statin.

 

There’s been some studies that show that they may elevate blood sugars a little bit which is ironic given what we just talked about with its use in diabetic patients. The benefits greatly outweigh the risk in that regard though.

 

And lastly there’s digestive problems like nausea, vomiting, diarrhea, constipation although these your body might actually adjust to over a short period of time like a few days or a week, or it could be solved by a slight dose adjustment or simply changing to a different statin.

 

The Controversy

 

But side effects aside, the debate centers around whether these medications are being prescribed too much or even when it’s not even necessary, and it brings in question about the best approach to managing heart health and if we’re even doing it right.

 

One of the main arguments is that statins may be given to people who could potentially manage their own cardiovascular issues through lifestyle changes alone, like dieting, exercise, and to quit smoking for smokers. 

 

So critics argue that for people who are at low risk, the benefits of using a statin might not outweigh the potential risks, especially considering the side effects we’ve discussed.

 

Along those same lines, one of the most contentious aspects of the statin debate is the concern that these drugs may lead some patients to neglect the lifestyle changes that are needed for long-term health. 

 

Statins are undeniably effective at lowering cholesterol, but they don’t address the root causes of high cholesterol. Poor diet, lack of exercise, smoking, and excessive alcohol consumption all contribute to heart disease, and just taking medicines currently can’t undo the damage bad behavior can or already caused. By providing a “quick fix,” statins might give patients a false sense of security, leading them to believe they are protected against heart disease regardless of their lifestyle choices.

 

For instance, imagine a patient who started taking a statin. They might continue eating a high-fat, high-sugar diet or avoid regular physical activity, thinking that the medicine alone will keep them healthy. This thought process can make patients skip the potential health benefits that come from lifestyle changes which goes way beyond just lowering cholesterol.

 

Another point that’s brought up is… at what cholesterol level someone should be at to need a statin. For a long time, the guidelines we use have increasingly added more populations to the list of statin recommendations, including people with no history of cardiovascular disease but who have risk factors like diabetes or slightly elevated cholesterol. 

 

Guidelines are based on huge studies showing that statins can prevent heart attacks and strokes, but some skeptics argue that using statins in more and more populations has led to unnecessarily giving medicine to relatively healthy people.

 

Also, and a bit more diabolical, there’s concern about the influence of pharmaceutical companies on the promotion of statins. Some skeptics think that the push for more statin use is driven, at least in part, by financial incentives rather than purely by the desire to keep patients healthier. 

 

And this could look really suspicious, causing people not to trust doctors when they want to prescribe a statin, especially when they are prescribed to people without any significant cardiovascular risk.

 

On the other hand, people who support statin use argue that these medications have been thoroughly studied for a long time and have proven they can save lives. 

 

They usually emphasize that cardiovascular disease is the leading cause of death in the world, and statins offer a simple, effective way to reduce this risk. For lots of people, particularly those at high risk, the benefits of statins far outweigh the potential downsides. 

 

Hard to argue with that one.

 

Beyond Whether To Use It, Is It Too Much?

 

And then there’s how much to give you.

One of the key issues is the concept of diminishing returns, where the additional benefit you get when you increase your statin dose is miniscule compared to the potential increase in side effects you could experience.

 

For example, a standard dose of a statin like atorvastatin (Lipitor) might lower LDL cholesterol by 30-40%. Doubling the dose may only lead to an additional 5-6% reduction in LDL levels. 

 

While this might seem good, the reduction in cardiovascular events from this extra drop in cholesterol is relatively small. Meanwhile, the likelihood of experiencing side effects like muscle damage or liver enzyme elevation, goes up at higher doses.

This concept of diminishing returns raises important questions about the optimal use of statins. Should patients be subjected to higher doses if the additional benefit is small? Or should the focus be on achieving a “good enough” level of risk reduction with lower, more tolerable doses? 

 

This puts into question the need for personalized medicine right? Where treatment plans are tailored to someone’s specific risks, preferences, and tolerance for potential side effects.

 

Alternative Perspectives: Is There Another Way?

 

Now we’re talking a lot about statins as though they’re the only medicine that can reduce cholesterol. There must be others right? And there is. Newer ones even. 

 

And they’re viable options especially if someone is experiencing side effects with statins.

 

One class of medication being PCSK9 Inhibitors which you might have heard of by the brand names, Praluent, or Repatha. These are injectable medications and are very effective at lowering cholesterol.

 

There’s bempedoic acid which is a pill by the name of Nexletol that actually works by preventing synthesis of cholesterol in the liver just like statins, but in a different way.

 

There’s an older medication called Zetia which reduces the absorption of cholesterol in the intestines. Not as powerful of a solution in most cases but it could do the trick for some people.

 

Right now,  statins are the main players in the risk reduction of cardiovascular disease and it’s been that way for a long time. Because of its longevity… the production and demand are so high, that costs of the medications are… reasonable and insurance companies are happy to pay for them.

 

And most patients by experience are going to treat themselves in proportion to available wallet size. So until the medications are more reasonably priced and insurance companies are able to comfortably cover them, it’s unlikely statins are going to move from its position for a long time.

 

So Wrapping Up, What Do I Think?

 

I used to think that it’s a one-size-fits-all endeavor. Going through pharmacy school, the emphasis of following guidelines was of utmost importance because it’s the pinnacle of evidence-based practice, the foundation of western medicine. 

 

If we apply what we know is best, to an extremely large population, then as a whole, we are on average healthier… right?

 

Maybe?

 

What I can tell you is when I’m talking to patients and I hear them complain about pill burden, like they feel overwhelmed at the number of medicines they’re taking, or they have side effects of medicines or a medicine is causing them to take another medication, which is called polypharmacy and is something we 100% try to avoid… you realize that every single person needs to be treated as though they’re the only one you’re going to see today, and that the treatment plan is mutual. 

 

I used to criticize my mom’s doctor. After her heart attack, they were giving her a statin 8x lower than the recommended dose following a cardiovascular event. A dose that has shown to significantly reduce the chances of another one.

 

But then if you take a step back and look at her as a whole person. Her LDL levels are very low, and her HDL levels (good cholesterol) are very high. We couldn’t reasonably expect to take her cholesterol any lower. Cholesterol is necessary for hormone production, vitamin D conversion, cell signaling. It’s a part of cellular membranes.

 

What problems would we potentially create by following our guidelines to the T?

 

But going back to the controversy. Do I think that statins are overprescribed?

 

To be honest, I’m a bit in the middle here. I think that the emphasis on lifestyle changes should be the mainstay. I know healthcare providers already do that, and we’re told to do that. Non-medication approaches are preferable in nearly all situations. But I think the expectations that patients have and the pressure placed on healthcare providers to fix problems now complicates priority.

 

And it kind of makes sense if you think about it. If you went to the doctor to help fix something that was wrong, would you prefer something that fixes your problem plus a few more down the line? Or would you rather fix what was wrong now, by taking a pill?

 

A lot of people would be a little upset if the answer to their problem is going to be found months down the line with leg work they have to do themselves.

 

So I think us as healthcare professionals have to do a better job treating patients in a holistic approach and that unfortunately might take more skill in communication rather than our medical degrees.

 

Because at the end of the day, we want people to be healthy. You want to be healthy.. But we have to remember that after the period of time we get to talk to each other, once you leave, you’re on your own.

 

So you have to remember that…

 

What we taught you, is more significant than what we gave you.

 

Outro

 

Well that’s our discussion of statins and cholesterol lowering medications today. If you thought this brought you any value at all, please subscribe to our newsletter at the bottom of the page and find us at our podcast titled Mini Med Minutes on most major Podcast Networks including Apple and Spotify.

 

Again thanks for tuning in and I’ll see you next time!

 

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