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Life on Statin Therapy: What You Should Expect: From their cardiovascular benefits to their potential side effects, here's what you need to know about these cholesterol medications.

For several decades, cholesterol-lowering statin medications have been at the forefront of cardiovascular disease management, as 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 be at some point.

"Statins lower LDL ("bad") cholesterol, and we know that lower LDL cholesterol is associated with a reduced risk of atherosclerotic cardiovascular disease (ASCVD)," says Luke Laffin, MD, with Cleveland Clinic's Section of Preventive Cardiology & Cardiac Rehabilitation. "Additionally, they lower inflammation, which we know is a causative factor in atherosclerosis and cardiovascular disease."

Yet, despite their many benefits, statins, like all medications, have some 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.

Statin Benefits

Statins inhibit the action of an enzyme responsible for cholesterol production in the 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 and also make plaques 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.

Although the statins belong to the same drug class, they differ in their potency and the degree of LDL lowering they can achieve (see "Meet the Statins" on Page 1). Your doctor will use a tool such as the American College of Cardiology/ American Heart Association (ACC/ AHA) risk calculator and other factors to gauge your long-term risk of ASCVD, determine your need for statin therapy, and guide in the choice of a statin.

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 will have one of the high-intensity statins that is 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."

Statin Side Effects

In addition to more common side effects such as headache and nausea, statins occasionally may cause an increase 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 suggestive of 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 cautions.

While some studies have identified positive effects of statins on cognitive function, some users have reported problems such as mental fogginess and forgetfulness, which subside after stopping the drug. Overall, though, large-scale clinical trials do not suggest an increase in cognitive problems associated with statin use, Dr. Laffin says.

One of the most noteworthy side effects of 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.

Some treatable conditions (such as thyroid dysfunction and severe vitamin D deficiency) may contribute to statin intolerance, as may consuming large quantities of grapefruit products and use of 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 do not recommend their use.

It's important not to stop taking your statin and to report any muscle side effects to your doctor. Your physician may switch you to a less-potent statin, change the dose, or explore alternative dosing strategies, such as taking the drugs every other day or less frequently. With some perseverance, you and your doctor 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[R]) or newer drugs known as PCSK9 inhibitors: alirocumab (Praluent[R]) and evolocumab (Repatha[R]).

Statins in Older Adults

Age is the most significant risk factor for ASCVD. 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 drug 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."

ARE YOU A STATIN CANDIDATE?

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

* Secondary prevention in people with established atherosclerotic cardiovascular disease (ASCVD).

* 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 ASCVD.

* Non-diabetic adults ages 40 to 75 with a 20 percent or greater likelihood of developing ASCVD in the next 10 years (high-risk patients).

* Non-diabetic patients ages 40 to 75 with an LDL level of 70 to 189 mg/dL and a 10-year ASCVD risk of 7.5 percent to less than 20 percent (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 [greater than or equal to]160 mg/dL, triglyceride levels persistently [greater than or equal to]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. The guidelines recommend considering coronary artery calcium scoring for people at intermediate risk in whom a decision about starting statin treatment remains uncertain.
MEET THE STATINS

EXAMPLES                    DOSAGE            LDL
                            (in milligrams)   REDUCED

High-Intensity

Atorvastatin                40-80 mg
(Lipitor[R])                                  50% or

Rosuvastatin                20-40 mg          more
(Crestor[R])

Moderate-Intensity

Atorvastatin                10-20 mg

Rosuvastatin                5-10 mg

Simvastatin                 20-40 mg
(Zocor[R])

Pravastatin                 40-80 mg
(Pravachol[R])

Lovastatin                  40-80 mg          30%-49%
(Altoprev[R], Mevacor[R])

Pitavastatin                1-4 mg
(Levalo[R])

Fluvastatin                 40 mg
(Lescol[R])                 (twice daily)

Fluvastatin XL              80 mg
(Lescol XL[R])

Low-Intensity

Simvastatin                 10 mg

Pravastatin                 10-20 mg          Less

Lovastatin                  20 mg             than 30%

Fluvastatin                 20-40 mg

Source: 2018 ACC/AHA Guideline on the Management of
Blood Cholesterol, Circulation, Nov. 10, 2018
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Publication:Men's Health Advisor
Date:Aug 27, 2019
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