When You Need Themand When You Dont
Your body makes a waxy substance called cholesterol. You also get it from food. Your body needs it, but too much cholesterol in your blood can clog your arteries. This increases your risk of heart disease, heart attack, and death.
Statins are drugs that lower your cholesterol. But if you are age 75 or older and you havent had symptoms of heart disease, statins may be a bad idea. Heres why:
Adults age 75 and older may not need statins.
Many older adults have high cholesterol. Their doctors usually prescribe statins to prevent heart disease.
But for older people, there is no clear evidence that high cholesterol leads to heart disease or death. In fact, some studies show the oppositethat older people with the lowest cholesterol levels actually have the highest risk of death.
Statins have risks.
Compared to younger adults, older adults are more likely to suffer serious side effects from using statins.
Statins can cause muscle problems, such as aches, pains, or weakness. Rarely, there can be a severe form of muscle breakdown.
In older adults, statins can also cause:
- Memory loss and confusion
- Nausea, constipation, or diarrhea.
Often, older adults take many drugs. These can interact with statins and lead to serious problems. Side effects, like muscle pain, may increase. Statins can also cause a fatal reaction when taken with heart-rhythm drugs.
Statins may increase the risk of type-2 diabetes and cataracts, as well as damage to the liver, kidneys, and nerves.
Do You Have High Cholesterol
Cholesterol is a waxy substance that your body uses to make cells, certain hormones, and vitamin D. High cholesterol can lead to the build-up of fatty sludge in your arteries in a process called atherosclerosis.
Atherosclerosis can cause serious health problems when it affects major blood vessels. These health problems are referred to as cardiovascular disease.
Depending on where the atherosclerosis is, the symptoms are different:
- Atherosclerosis of the arteries that nourish the heart can cause heart attacks, heart failure, chest pain , or abnormal heart rhythms.
- Atherosclerosis of the arteries in the neck can cause stroke, mini-stroke , or vascular dementia.
- Atherosclerosis of the arteries in the legs can cause pain, slow-healing wounds, skin ulcers, or dead tissue .
- Atherosclerosis of the arteries that feed the kidneys can cause kidney failure or high blood pressure.
- Atherosclerosis of the aorta, the largest artery in the abdomen, can cause a ruptured aorta with life-threatening internal bleeding.
Statin Drug And Food Interactions
Some foods and medications donât mix well with statins and can make side effects worse:
- Grapefruit juice, which has chemical that can change the way your body breaks down statins
- A drug for irregular heart rhythms called amiodarone
- Gemfibrozil , a cholesterol drug
- Protease inhibitors, a type of HIV medication that includes saquinavir and ritonavir
- Some antibiotic and antifungal drugs, such as clarithromycin and itraconazole
- Certain medications, such as cyclosporine, that lower your immune system activity
There are other medications that can cause problems if you take them with statins. You should tell your doctor about all over-the-counter or prescription drugs, herbal supplements, or vitamins that you use.
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Dietary Factors That Tend To Reduce Ldl Cholesterol
Soluble fiber helps to lower blood cholesterol levels. It dissolves in water to form a gel that moves slowly through the intestines, grabbing up fat, dietary cholesterol, bile salts, and sugar to be excreted. Once excreted, these are no longer available to build more cholesterol.
Load up on foods high in soluble fiber like beans, such as hummus, lentil stew, dal, bean burritos, bean soup, bean burgers, bean dips. There are endless options to incorporate beans into your diet. Oats and barley are also high in soluble fiber. Try having steel-cut or overnight oatmeal for breakfast, use rolled oats to make pancakes, or make a delicious barley risotto. Incorporate soluble-fiber-rich vegetables like eggplant, okra, carrots, and potatoes into your diet to help lower cholesterol. This also includes dark, leafy greens such as kale, spinach, and collard greens. Pectin is a soluble fiber that works by binding to fatty substances in the digestive tract, including cholesterol, and promotes their elimination. Pectin-rich fruits such as apples, grapes, citrus fruit, and strawberries can help lower LDL.
Myth #: Taking Statin Drugs Leads To Diabetes Out Of The Blue
Truth:;In clinical trials, statins appear to accelerate a diagnosis of adult-onset diabetes because they cause a slight elevation in blood sugar. However, people experiencing this side effect already have higher than normal blood sugar, or prediabetes, explains Martin. For those who are borderline diabetic, the mild increase in blood sugar can lead to a diabetes diagnosis about five weeks earlier than it would be otherwise.
Research indicates that statin drugs do not induce diabetes in someone who isnt already nearing a diabetes diagnosis. Additionally, the benefits of reducing cardiac events in someone who has prediabetes or is diabetic greatly outweigh the mild increase that might occur in their blood sugar, says Martin.
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Effect On Inclisiran On Lipid And Lipoprotein Levels
HETEROZYGOUS FAMILIAL HYPERCHOLESTEROLEMIA
The effect of inclisiran on LDL-C levels was determined in patients with heterozygous familial hypercholesterolemia who were randomized to receive subcutaneous injections of inclisiran 284mg or placebo on days 1, 90, 270, and 450 . The mean baseline LDL-C level was 153Â±54mg/dl and 90% of the patients were receiving statins with most on high intensity statins . At day 510 LDL-C levels were reduced by 47.9% compared to placebo . The reduction in LDL-C was similar in all genotypes of familial hypercholesterolemia. Total cholesterol was reduced by 33%, non-HDL-C by 44%, Lp by 17.2%, and triglycerides by 12%. HDL-C and hsCRP were not markedly altered.
HOMOZYGOUS FAMILIAL HYPERCHOLESTEROLEMIA
A small study reported that inclisiran treatment lowered LDL-C levels in 3 of 4 patients with homozygous familiar hypercholesterolemia but less than that seen in individuals with fully functioning LDL receptors .
Are There Differences Among Statins
Statins differ in several ways. The most obvious difference is in their ability to reduce cholesterol. Currently, atorvastatin and rosuvastatin are the most potent, and fluvastatin is the least potent.
The statins also differ in how strongly they interact with other drugs. Specifically, pravastatin and rosuvastatin levels in the body are less likely to be elevated by other drugs that may be taken at the same time as the statins. This is so because the enzymes in the liver that eliminate pravastatin and rosuvastatin are not blocked by many of the drugs that block the enzymes that eliminate other statins. This prevents the levels of pravastatin and rosuvastatin from rising and leading to increased toxicity such as myopathy . For example, in scientific studies, patients who took both verapamil and simvastatin experienced myopathy 10 times more often than patients who received simvastatin alone because verapamil increased the blood levels of simvastatin.
Statins differ in the frequency with which they cause a severe type of myopathy called rhabdomyolysis, in which muscles are severely damaged. Cerivastatin was withdrawn from pharmacies worldwide because it caused rhabdomyolysis 10 to 100 times more often than other statins. Rhabdomyolysis may occur more often in patients taking statins with drugs that also cause rhabdomyolysis or drugs that increase the blood concentration of the statin.
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Effect Of Pcsk Inhibitors On Lipid And Lipoprotein Levels
There are a large number of studies that have examined the effect of PCSK9 inhibitors on lipid and lipoprotein levels. A meta-analysis of 24 studies comprising 10,159 patients reported a reduction in LDL-C levels of approximately 50% and in an increase in HDL of 5-8% . Notably, in 12 RCTs with 6,566 patients, Lp levels were reduced by 25-30% . The higher the baseline Lp the greater the reduction with treatment . It should be recognized that most LDL-C lowering drugs do not lower Lp levels. PCSK9 inhibitors have not been shown to decrease hs-CRP levels .
Both alirocumab and evolocumab have been studied as monotherapy vs. ezetimibe. In the Mendel-2 study patients were randomly assigned to evolocumab, placebo, or ezetimibe . In the evolocumab group, LDL-C levels decreased by 57% while in the ezetimibe group LDL-C levels decreased by 18% compared to placebo. Additionally, non-HDL-C was decreased by 49%, apolipoprotein B by 47%, triglycerides by 5.3% , and Lp by 18.5% while HDL levels increased by 5.5% in the evolocumab treated subjects. In a study of alirocumab vs. ezetimibe, LDL-C levels were reduced by 47% in the alirocumab group and 16% in the ezetimibe group . In addition, alirocumab decreased non-HDL-C by 41%, apolipoprotein B by 37%, triglycerides by 12%, and Lp by 17% and increased HDL by 6%. Thus, PCSK9 monoclonal antibodies are very effective in lowering pro-atherogenic lipoproteins when used in monotherapy and have a more robust effect than ezetimibe.
Dietary Factors That Tend To Elevate Ldl Cholesterol
Dietary saturated fat intake has been shown to increase LDL cholesterol. Saturated fats occur naturally in many foods; dairy products, meat/seafood, and eggs contain both saturated fat and cholesterol. Dairy products are the leading source of saturated fat in Western diets. Avoidance of even low-fat dairy products is helpful for control of lipids, given that these cause small but significant increases in LDL.
Plant-based foods that contain saturated fats include coconut, coconut oil, coconut milk, and cocoa butter, as well as palm oil and palm kernel oil. Despite intense commercial promotion of some of these products, their effect on blood lipids is similar to that of animal-derived saturated fat. Coconut oil proponents try to argue that coconut oil has medium chain triglycerides which are shorter-chain saturated fats that arent as bad as the longer-chain saturated fats in meat and dairy. But you cant apply the MCT research to coconut oil. MCTs make up only about 10% of coconut oil. The majority of coconut oil is the LDL-raising longer-chain saturated fats, lauric and myristic.
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How Statins Work And Why Theyre Not Enough
To talk about statins, we first need to talk a little about cholesterol. When you hear the word cholesterol, it is referring to one of two sorts.
First, there is blood cholesterol. Most of it comes from the liver. The liver produces cholesterol because our bodies need it for all kinds of reasons. Cholesterol helps our cells do their jobs. It is also an integral part of several hormones. We would not exist without blood cholesterol, but then again, neither would heart disease.
There’s cholesterol in your blood , and cholesterol you eat .
Blood cholesterol is also the number were referring to when we say, My cholesterol level is . . .
Heres one really important point: Our liver manufactures all the cholesterol we need.
The second type of cholesterol is dietary cholesterol. This is the cholesterol we eat. Major sources include egg yolks, organ meats like liver, and shrimp.
If we eat too much dietary cholesterol, we can raise our blood cholesterol somewhat, but what really sends our blood cholesterol soaring are saturated fats and trans fats. Foods full of saturated fat include red meat, butter, cheese, cream, whole milk, palm oil, and coconut oil. Foods with trans fats include anything that has partially hydrogenated oils in its ingredient list, such as many store-bought cakes, pies, and cookies as well as biscuits, donuts, and some margarines.
Who Should Not Take Statins
Before prescribing a statin to anyone with liver disease, a doctor should thoroughly discuss the risks and possible benefits. If the liver disease is stable and chronic, taking a low-dose statin may carry greater benefits than risks. If the liver disease is progressive, however, guidelines warn against using statins.
If liver disease develops while taking a statin, the persons doctor may recommend reducing the dosage of the statin, switching statins, or stopping their use.
People who are pregnant, breastfeeding, or intending to become pregnant should not take statins.
It is typically not safe to combine statins with:
- erythromycin, an antibiotic
- a person has peripheral arterial disease
- after a heart attack or stroke
- if a blood test gives an LDL cholesterol reading of 190 milligrams per deciliter or higher
- if the reading is 70 mg/dl or higher in people aged 4075 with diabetes
- if the reading is 70 mg/dl or higher in people aged 4075 with a high risk of developing heart disease or a stroke
Atherosclerosis can develop and form plaques even when blood cholesterol levels are low. Statins may benefit people who already have atherosclerosis or have a high risk of developing it, even if they do not have high cholesterol levels.
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Pharmacokinetics And Drug Interactions
Statins have different pharmacokinetic properties which can explain clinically important differences in safety and drug interactions . Most statins are lipophilic except for pravastatin and rosuvastatin, which are hydrophilic. Lipophilic statins can enter cells more easily but the clinical significance of this difference is not clear. Most of the clearance of statins is via the liver and GI tract . Renal clearance of statins in general is low with atorvastatin having a very low renal clearance making this particular drug the statin of choice in patients with significant renal disease. The half-life of statins varies greatly with lovastatin, pravastatin, simvastatin, and fluvastatin having a short half-life while atorvastatin, rosuvastatin, and pitavastatin having a long half-life . In patientâs intolerant of statins, the use of a long-acting statin every other day or 2 times per week has been employed. Short acting statins are most effective when administered in the evening when HMG-CoA reductase activity is maximal while the efficacy of long-acting statins is equivalent whether given in the AM or PM . In patients who prefer to take their statin in the morning one should use a long-acting statin.
Thus, despite the excellent safety record of statins, careful attention must be paid to the potential drug-drug interactions. For additional information see Kellick et al .
Who Should Take Them
Statins are often recommended to help prevent a first heart attack or stroke .
They are also used to reduce the risk of having a repeat heart attack or stroke; in someone who has already had one .
- Know you have heart disease or have a history of stroke, heart attack, peripheral vascular disease or chest pain, also called angina
- Have high cholesterol or know you have Familial Hypercholesterolemia
- Are between 40 and 75 years of age and also have diabetes
- Are between 40 and 75 years of age and your clinician estimates how likely you are to have a heart attack or stroke or die from one in the next 10 years , and your risk is high enough to benefit from being on one
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Truths About Statins And High Cholesterol
For every drop of scientific evidence that statins are safe and effective, there is a tidal wave of misinformation. Our patients are concerned about statin side effects theyve heard about from family or friends, or read about on the Internet.Statins are the gold-standard for high cholesterol treatment. Theyre a powerful medication, and theyve been proven to save the lives of many men and women living with or having a high risk of heart attack or stroke.But if statins are so effective, why are some people afraid to take them?As with any medication, there are risks associated with taking statins, but the benefits far outweigh the risks for the vast majority of high-risk patients.In an effort to put statin side effects into context and provide honest, scientific answers about statins and their use, weve put together a list of common questions our patients ask us:
Who Can Take Statins
You might be prescribed a statin if you have heart disease or another disease of the heart and blood vessels, or if you are at risk of developing them in the next 10 years.
If you have high cholesterol
You should be offered a statin if you have high cholesterol and lifestyle changes havent been enough to bring it under control.
Depending on your cholesterol levels and how healthy you are otherwise, you and your doctor or nurse might want you try to bring your cholesterol levels down with a healthy diet and lifestyle first, before starting statins.
If you are at risk of developing heart disease
You will probably be prescribed a statin if you are at high risk of developing heart disease;or;a disease of the blood vessels. For example, if you have:
- rosuvastatin .
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Your Personal Risk Of Heart Attack Or Stroke
Remember: If your health care team suggests that you take a statin, its all to help lower the chances that you will have a heart attack or stroke caused by atherosclerotic cardiovascular disease .
ASCVD develops because of a buildup of sticky, cholesterol-rich plaque. Over time, this plaque can build up and narrow the arteries.
Your care team may have already talked with you about how a risk calculator can be used to find your risk of developing ASCVD or having a heart attack or stroke. This calculator factors in things like:
- Your age
- Systolic blood pressure
- If you smoke
- If you have diabetes
Your care team may also consider other factors that play a role or affect your risk. Because your risk can change over time, its important to keep talking with your care team about what steps you can take to stay healthy as you age.
Keep in mind that making lifestyle changes in addition to taking a statin or other medication can help protect your heart and improve your overall health.