Statins: good drugs for bad cholesterol   (January 23, 2011)

Statins (technically, HMG-CoA reductase inhibitors) are a very important class of prescription medications. The drugs in this class typically have names ending in "statin:" atorvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, et. al., hence the nickname.

What do statins do? The major effect of the statins is to lower LDL-cholesterol ("bad cholesterol") levels, and they lower LDL-cholesterol better than other classes of drugs. They do this by inhibiting an enzyme with the long-winded name HMG-CoA reductase, that controls the rate of cholesterol production in the body. Statins slow down the production of cholesterol and increase the liver's ability to remove  LDL-cholesterol that is already in the blood. Statins also reduce elevated triglyceride levels and produce a modest increase in HDL-cholesterol ("good cholesterol").

Statins are proven to reduce the risk of heart attack and stroke.  The manufacturers of these drugs have done zillions of studies, which repeatedly demonstrate the favorable effects of decreasing LDL-cholesterol in patients with preexisting heart disease, and in prevention in high-risk individuals. And in patients with diabetes as well as patients without diabetes. Indeed, one major study (the Heart Protection Study) suggested that most adults with diabetes should be taking statins even if they have normal cholesterol levels and no evidence of heart disease. The study found that statin drugs cut the risk of heart attacks, strokes and the need for angioplasty or bypass surgery in people with diabetes by one-third.

Thanks to their track record in these studies, statins have become the drugs most often prescribed when a person with heart disease needs a cholesterol-lowering medicine.

The statins are well tolerated by most patients, and serious side effects are rare. Some patients will have gut symptoms such as gas, constipation, or abdominal pain or cramping, which usually go away as the body adjusts. Rarely a patient will develop abnormalities in liver laboratory testing. Another rare side effect is  muscle problems, ranging from muscle aches to a potentially life-threatening problem called rhabdomyolysis. One statin (cerivastatin, brand name Baycol) was withdrawn from the market after numerous reports of rhabdomyolysis. Other statins are considered to have only a small risk.

So, the statins are very efficacious, and side effects are generally mild or rare. The end result is that cardiologists and indeed most physicians have made statins amongst the most popular (and most profitable) drugs that were ever developed. For example, according to the the manufacturer, Pfizer, their statin (Lipitor, AKA atorvastatin), with 2008 sales of 12.4 billion dollars, was the "world's largest-selling branded pharmaceutical."

Yet there has developed a certain degree of negativism about using statins on the internet. Some may be driven by the financial aspects of the drug industry, sometimes by people who have experienced side effects (see Statin Rage) and sometimes by blatent hucksterism. For example, I just saw an Internet ad, and clicking through, read the following: "Lower Cholesterol Can Kill You! Forget the myths about cholesterol and animal fat. And forget all of those cholesterol-lowering drugs... The mainstream medical community wants to feed you expensive prescription drugs and deny you the foods you love like steak and eggs in order to lower your cholesterol." The good doctor writing this is pitching his books and supplement products, and like other snake-oil salesmen, mixes fact and fancy to make a fast buck from gullible patients.

I think that the scientific evidence is overwhelming. Statins help. And that's because numerous large studies (underwritten by the pharmaceutical companies but reviewed and approved by the FDA if the company wants to add a label claim) say so. Testimonial data from folks who've suffered side effects or want to pitch their products just doesn't influence my thinking.

I'm on a statin. Are you?