What You Should Expect From Statin Therapy

Cholesterol-lowering statin medications have been at the forefront of managing cardiovascular disease for several decades now. Why? It’s because a large body of research supports their benefits in reducing the risk of heart attack and stroke.

The drugs have become so universally used that if you haven’t been prescribed a statin already, chances are you will at some point.

Preventive cardiologist Luke Laffin, MD, says statins lower your LDL ( or “bad”) cholesterol, which is associated with a reduced risk of atherosclerotic cardiovascular disease. (That’s the buildup of cholesterol, fatty cells and inflammatory deposits on the inner walls of your arteries aka “hardening” or “clogging” of the arteries).

“Additionally, statins lower inflammation, which we know is a factor that causes atherosclerosis and cardiovascular disease,” Dr. Laffin says.

Yet, despite their many benefits, statins (like all medications) have some important side effects you need to know about. So, review the risks and benefits of these important medications with your physician, and discuss your need for statin therapy.

What are the benefits of statins?

Statins inhibit the action of an enzyme that’s responsible for cholesterol production in your liver. In the process, they significantly reduce LDL and total cholesterol, while also having beneficial effects on HDL (“good”) cholesterol, triglycerides and inflammation. Some evidence suggests that high-intensity statin therapy may help to slow, and potentially reverse, the growth of artery-clogging atherosclerotic plaques. They may also make them less prone to rupture and cause heart attacks and strokes.

“There are good data to suggest that the more LDL lowering we can achieve, the lower the risk of adverse cardiac events such as strokes and heart attacks,” Dr. Laffin explains.

Your doctor will use a tool like the American College of Cardiology/American Heart Association risk calculator and other factors to gauge your long-term risk of atherosclerotic cardiovascular disease, determine if you need statin therapy, and if so, which one.

The statins are generally taken once daily and are available in generic forms. “It’s important to note that atorvastatin and rosuvastatin really are the workhorses of cardiology and statins at this point,” Dr. Laffin adds. “A lot of pharmacies typically will have one of the high-intensity statins. They’re inexpensive and easy to obtain. In my experience, 99% of insurance companies cover at least one of them, and more than 75% cover both of them.”

Are you a candidate for a statin?

Guidelines from the American College of Cardiology and American Heart Association recommend statin therapy for:

• Secondary prevention in people with established atherosclerotic cardiovascular disease.
• People with an LDL cholesterol level of 190 milligrams per deciliter (mg/dL) or higher, due to a genetic condition.
• People with diabetes ages 40 to 75 with an LDL level over 70 mg/dL and no atherosclerotic cardiovascular disease.
• Adults who do not have diabetes ages 40 to 75 with a 20% or greater likelihood of developing atherosclerotic cardiovascular disease in the next 10 years (high-risk patients).
• Adults who do not have diabetes ages 40 to 75 with an LDL level of 70 to 189 mg/dL and a 10-year ASCVD risk of 7.5% to less than 20% (intermediate risk) if the risk estimate and presence of certain risk-enhancing factors* favor treatment.

* These factors include a family history of ASCVD, LDL levels persistently ≥160 mg/dL, triglyceride levels persistently ≥175 mg/dL, chronic kidney disease, ethnicity, inflammatory diseases, metabolic syndrome, and (in certain people, if measured) results of high-sensitivity C-reactive protein, lipoprotein(a), and apolipoprotein B. Note: The guidelines recommend considering coronary artery calcium scoring for people at intermediate risk in whom a decision about starting statin treatment remains uncertain.

What are the side effects of statins?

Elevated liver enzymes. In addition to more common side effects such as headache and nausea, statins occasionally may cause increases in liver enzymes, suggesting liver inflammation. However, the latest ACC/AHA guidelines recommend liver-enzyme testing only for statin users who are at higher risk or have symptoms that may suggest liver toxicity. Furthermore, statins may cause small elevations in blood sugar, enough to push some people into the range of type 2 diabetes. “But, we know that the benefits of statins outweigh that small increase in blood glucose across multiple populations,” Dr. Laffin notes.

Mental fogginess. While some studies have identified positive effects of statins on cognitive function, some users have reported problems like mental fogginess and forgetfulness, which go away after stopping the drug. Overall, though, large-scale clinical trials don’t suggest an increase in cognitive problems associated with statin use, Dr. Laffin says.

Muscle pain. One of the most noteworthy side effects associated with statin therapy is muscle aching and stiffness, which can be more severe as the statin dose and potency increase and may make some people intolerant to the drugs. Certain statins — in particular, atorvastatin and simvastatin — are more likely to cause these side effects, while others, like rosuvastatin and pravastatin, have less of an effect.

How to minimize side effects

Some treatable conditions (like thyroid dysfunction and severe vitamin D deficiency) may contribute to statin intolerance. So may consuming large quantities of grapefruit (or juice) and taking certain medications. Addressing these factors may ease or prevent statin-related muscle effects. Also, some people have found that taking coenzyme Q10 supplements may help, although the ACC/AHA guidelines don’t recommend their use.

It’s important not to stop taking your statin and to report any muscle side effects to your physician. Your doctor may switch you to a less-potent statin, change the dose, or explore alternative dosing strategies. This may include taking the drugs every other day or less frequently. With some perseverance, you and your physician can develop a statin regimen that works for you.

“Usually, you can find at least some dose of statin that people can tolerate, even if it is just a couple times a week,” Dr. Laffin says. “If you absolutely cannot tolerate a statin at any dose, then we have other medications we can use,” such as ezetimibe (Zetia®) or newer drugs known as PCSK9 inhibitors: alirocumab (Praluent®) and evolocumab (Repatha®).

What you need to know about statin use in older adults

Age is the most significant risk factor for atherosclerotic cardiovascular disease. However, the risks and benefits of statins must be carefully considered in older populations, especially those with health problems.

Older adults, as a whole, may be more likely than their younger counterparts to experience serious side effects from statins. Many seniors take multiple medications, making them more likely to experience adverse medication interactions with a statin. Importantly, seniors with other medical conditions that shorten their life expectancy may not reap the benefits of statin therapy.

So, if you’re over age 75 — and especially if you have other health problems — discuss the pros and cons of statin therapy with your physician, Dr. Laffin advises.

“The effects of statins are usually over the long term—we’re talking five to 10 years in terms of cardiovascular risk reduction,” he explains. “So, you have to balance the risk of taking another medicine versus whether you are going to die from something else in those five to 10 years. I think it’s very reasonable for someone who has other competing comorbidities to talk about deprescribing statins.”

This article first appeared in Cleveland Clinic Men’s Health Advisor.