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Are You Taking the Right Treatment For Your High Cholesterol?

Our analysis and new guidelines could change your choice

Last updated: February 2018

At-a-Glance

Cardiovascular disease is responsible for 1 in 7 deaths in the U.S., mostly due to heart attacks and strokes. Both of those can be triggered by fatty cholesterol deposits that build up in or break off from arteries that carry blood to the heart and brain. That build-up of plaque is known as atherosclerosis.

The body needs some cholesterol to maintain good health. But for those who need to reduce the risk of a heart attack or stroke, statin drugs lower the level of “bad” cholesterol (low-density lipo­protein, or LDL) in the blood by blocking a liver enzyme needed to make cholesterol. Statins may also decrease inflammation in arteries, and help raise “good” cholesterol, (high-density lipoprotein or HDL) levels.

Our recommendations about who should consider a statin to lower their cardiovascular risks are based on 2016 guidelines from the U.S. Preventive Services Task Force, and informed by guidelines from the American College of Cardiology and the American Heart Association.

These guidelines consider your overall risk of a heart attack or stroke in the next 10 years, as determined by a variety of risk factors, not just your LDL cholesterol levels. The guidelines suggest those risks include your age, blood pressure level, whether you smoke, are overweight, or have diabetes or other medical problems.

Diet and lifestyle changes, such as quitting smoking, losing weight if you need to, and exercise, can help lower your risk of heart attack and stroke. And in some cases, those steps can reduce your risk enough so that you may not need a statin.

Who Needs a Statin?

You should take a statin if you’ve previously had a heart attack or stroke, been diagnosed with coronary artery disease or atherosclerosis, or had a heart artery blockage discovered before a heart attack and had either angioplasty or bypass surgery. 

You also need a statin if you have a hereditary condition called hypercholesterolemia, which is characterized by having very high LDL cholesterol levels.

If you’ve not had a heart attack or stroke, and are age 40 or over, use an online calculator developed by the American College of Cardiology to find your overall 10-year risk of having a heart attack or stroke. You can find it here: http://tools.acc.org/ASCVD-Risk-Estimator/. You’ll need your most recent cholesterol results and systolic (the upper number) blood pressure reading in hand. The ideal risk is less than 7.5 percent.

This calculator generated controversy when it was released in November 2013. Some experts argued it might overestimate a person's risk, and could put people on a statin who don't actually need one. 

It's good to know that this and other calculators are intended to help estimate your overall cardiovascular risk. The results are simply a guide for you and your doctor to use in deciding if you should take a statin.  

Once you learn your 10-year risk score, see if any of these situations apply to you:

If you are between 40 and 75 years old and have diabetes, high cholesterol, high blood pressure, or if you smoke:


• If your risk is 10 percent or greater, or, if your LDL level is 190 mm/dL, or over, a low- to moderate-dose of a statin drug is advised.


• If your risk is 7.5 to 9.9 percent, statins might lower that risk but fewer people in this group will benefit from treatment because there is a lower risk of having a cardiovascular event. For people in this group, our medical consultants advise trying lifestyle changes first. Stopping smoking, losing excess weight, getting adequate exercise, consuming a heart-healthy diet, drinking alcohol in moderation only, and getting blood sugar levels under control can go a long way to reducing your risk of having a heart attack or stroke.


In fact, according to a 2016 analysis in the New England Journal of Medicine, a healthy lifestyle can cut the risk of a heart attack or other coronary event by a third to one-half, even among people with a family history of the disease.


If diet and lifestyle changes don’t lower your calculated risk enough after three to six months, you and your doctor can consider a statin, even if your LDL cholesterol isn’t elevated.


For those 76 years or older, with no previous history of cardiovascular disease:


• Most doctors will apply the same rules as for 40 to 75 year olds. But the USPSTF found insufficient evidence to make a firm recommendation about starting statin use in this group who don’t have heart disease.


The main reason for this is that most of the studies conducted over the last 20 years failed to include enough people aged 75 and over.  


But most cardiologists believe strongly that statins confer the same heart attack and stroke lowering benefits in this age group.  


“The physiology and biology do not change once you hit 75,” says Steven Nissen, M.D., head of cardiology at the Cleveland Clinic. “And there’s no evidence indicating the benefits are not the same for older people.”


Roger Chou, M.D., a professor of medicine at Oregon Health & Science University who led the team that conducted the analysis of statin studies for the USPSTF, agrees. “It’s reasonable to assume the reduction in risk would be the same,” he told Consumer Reports.


How Effective Are Statins?

Seven statins are now available by prescription in the U.S. They are:

Generic Name Brand Name(s) Available As A Generic Drug?
Atorvastatin Lipitor Yes
Fluvastatin Lescol, Lescol XL Yes  
Lovastatin Altoprev, Mevacor Yes
Pitavastatin Livalo No
Pravastatin Pravachol Yes
Simvastatin Zocor Yes
Rosuvastatin Crestor Yes

All the statins have been found to reduce LDL cholesterol. However, the statins differ in their strength and ability to reduce LDL cholesterol at various doses. For example, rosuvastatin (Crestor) and atorvastatin (Lipitor) are the most potent of the statin drugs, and so are preferred by many doctors when treating people with established heart disease, or people who have had a heart attack or stroke.    

The various treatment guidelines consider the remaining statins equivalent in strength at their various doses.   

Overall, for people being prescribed a statin to prevent the onset of heart disease and to prevent a first heart attack or stroke, all the statins can be considered equally effective.

How Safe Are Statins?

Overall, statins appear to be quite safe, though some precautions are important to keep in mind.

First, because of the risk for birth defects, women who are pregnant or trying to become pregnant, should not take any statin drug. Women who are breastfeeding should not take a statin as well.

In addition, statins can have two important adverse effects: muscle tissue damage and liver damage.

Muscle tissue damage

Statins can cause muscle aches, soreness, tenderness, or weakness. Contact your doctor immediately if you experience any of those symptoms, as well as nausea, vomiting, stomach pain, brown- or dark-colored urine, or simply feel tired even though you slept well.

While those symptoms usually go away after you stop taking the drug, they can be signs of a rare, life-threatening form of muscle breakdown called rhabdomyolysis. This can lead to permanent kidney damage and coma.

Larger statin doses raise those risks. So does taking a statin, particularly simvastatin, in combination with certain other drugs, including:   

  • The antibiotics erythromycin, clarithromycin, telithromycin
  • The antifungal medications itraconazole, ketoconazole, posaconazole
  • Cyclosporine, an immunosuppressant
  • Danazol, for endometriosis
  • Nefazodone, an antidepressant
  • Amiodarone, for irregular heartbeat
  • Amlodipine, for high blood pressure
  • Ranolazine, for angina (chest pain)
  • Gemfibrozil, to reduce cholesterol
  • Niacin, to reduce cholesterol
  • Verapamil, for high blood pressure

The cholesterol-lowering drug ezetimibe (Zetia) has been associated with muscle aches and rhabdomyolysis when used on its own and in combination with statins.

Other factors that increase the risk of rhabdomyolysis include alcoholism, low phosphate levels, and extreme exercise (such as running a marathon).

Less common issues: Diabetes, memory and liver problems

The Food and Drug Administration says patients prescribed a statin should have liver function tests before starting treatment. Contact your doctor immediately if you develop signs of liver problems, which include unusual fatigue or weakness, loss of appetite, dark-colored urine, or your skin or whites of your eyes begin to turn yellow.

Statins also pose a small risk of type 2 diabetes. The FDA added that risk after some research linked the drugs to elevated blood sugar levels and diabetes.

The FDA says statins may also cause memory loss, forgetfulness, and confusion.

Age, Race, and Sex Differences

The benefits of statins are less certain for women who have only slightly elevated LDL and don’t have a history of heart disease or other risk factors.

At any particular age and LDL level, women generally have a much lower risk of heart disease than men. So if your risk is low and your doctor suggests a statin, be sure to understand just how much taking one would lower your 10-year, overall risk of having a heart attack or stroke.

While women have been under-represented in the major statin studies, the research to date suggests that the drugs pose similar risks to both genders. And while there’s little research into the safety of the drugs in people older than 65, all meds pose extra risks to older people, so should be used with extra caution.  

Finally, some research suggests that rosuvastatin (Crestor and generic) may be more potent in people of Asian heritage (Filipino, Chinese, Japanese, Korean, Vietnamese, or Asian-Indian), so your starting dose needs to be lower than normal.

Warning About High Doses

Because higher doses of a statin, and high intensity statins, reduce LDL cholesterol more, the hypothesis has been that they are better and should be used more liberally. Some treatment guidelines recommend high-intensity statins if a person does not have any conditions or problems that prohibit their use.

But higher doses and high-intensity statins come with more side effects. Higher doses of all statins have been linked to muscle aches, soreness, tenderness, or weakness. Studies indicate that between one in 20 to one in 10 people who take a statin—regardless of dose—experience these symptoms, and up to 10 percent in some studies have not been able to tolerate an 80 mg dose.

Higher doses have also been linked to an increased risk of a life-threatening form of muscle breakdown called rhabdomyolysis. This can lead to permanent kidney damage, coma, and death.

So even if you fall into a category that should receive a high-intensity statin, we advise caution and careful monitoring for the occurrence of side effects.

People With Special Considerations

The table below presents statin recommendations for people who take medications for specific medical conditions. If you have one of these conditions, you should discuss it with your doctor so he or she can help you determine which statin is the safest and most effective for your situation.

In particular, medicines for HIV and AIDS and those used to prevent the rejection of transplanted organs can increase the toxicity of statins. Statins can also increase the effect of blood thinners, such as warfarin (Coumadin and generic), and can interact with many other medications, including those used to control blood pressure.

This is not a comprehensive list. Your doctor may advise you to take a particular statin if you have other conditions or chronic diseases. It’s wise to tell your doctor about any prescription or nonprescription medicine and dietary supplements you are taking, as well as any medical conditions you have. And you should always carefully read the labeling or package insert that comes with your medicine. It contains essential information about how to take the medication and side effects and drug interactions you should be aware of.

Statin Choices for People With Special Considerations

Condition or other drugs you may be taking Frequently recommended statins1 Comment
Kidney transplant patients taking cyclosporine

-Fluvastatin (Lescol)

-Pravastatin (Pravachol and generic)

Both are safe and effective. Lescol is less proven than pravastatin.
HIV positive patients taking protease inhibitors2

-Atorvastatin (Lipitor and generic)

-Fluvastatin (Lescol)

-Pravastatin (Pravachol and generic)

Low doses are strongly advised.
Patients taking gemfibrozil (Lopid) (a type of cholesterol-lowering drug)

-Atorvastatin (Lipitor and generic)

Gemfibrozil combined with a statin increases the risk of rhabodomyolysis, which can lead to kidney failure and death.
Patients taking the blood thinner warfarin (Coumadin and generic)

-All statins

May require adjustment in dose of warfarin.

1. Because they have been shown effective in this population of patients.

2. Protease inhibitors include indinivir, nelfinavir, ritonavir, saquinavir, amprenavir, and the combination drug lopinavir/ritonavir.

Our 'Best Buy' Picks

All statins work equally well, pose similar risks, and most are available as low-cost generics. So the right choice for you depends on other factors, such as which one your insurance covers best.
 

You may also consider which statins are offered on a retail pharmacy’s discount generic drug list. For example, at Walmart, 10 mg and 20 mg of lovastatin can be purchased without insurance for $4 for a month’s supply or $10 for a three-month supply. Or you may find discount drug coupons by visiting GoodRx.com, typing in the drug name, strength and quantity as well as your location, and comparing the results for pharmacies in your area.

How We Made Our Recommendations

Our evaluation is based in part on an independent scientific review of the studies and research literature on statin drugs conducted by a team of physicians and researchers at the Pacific Northwest Evidence-Based Practice Center. This analysis reviewed 347 studies, including 225 clinical trials, 80 observational studies, and 21 systematic reviews. The analysis also included studies conducted by the drugs’ manufacturers. This effort was conducted as part of the Drug Effectiveness Review Project, or DERP. DERP is a first-of-its-kind, multistate initiative to evaluate the comparative effectiveness and safety of hundreds of prescription drugs.


This update of our previous statin report also relied on a recent review of combination therapies conducted for the Agency for Healthcare and Research Effective Healthcare Program. It is available here.


References

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Editor's Note:

These materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multistate settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).



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