Statins: Bad cholesterol’s nightmare

Statins sounded Greek to many a decade ago. Now, it is already a household term to many who associate this type of drugs with effective cholesterol-lowering.

It’s called the nightmare of low-density lipoprotein (LDL), which is the bad cholesterol. Statins significantly reduce LDL. They are the ally of the high-density lipoprotein (HDL), the good cholesterol, which helps clear LDL from the circulation. Statins slightly increase HDL.

Statins work in the liver and block a key chemical step that is important in manufacturing cholesterol. There is now no question that statins, as a group, are one of the most effective therapies to lower LDL cholesterol.

There are multiple, large, powerful research trials to date involving over 50,000 participants using practically all of the statins available in the market. The trials are relatively uniform in what they show. Use of a statin can lower the chances of having a heart attack or any serious cardiovascular complication anywhere from 25 to 40 percent.

Some of the trial names, which may be mentioned in health articles, are Scandinavian Simvastatin Survival Study or 4S, West Scotland, Care, Lipid and Heart Protection Studies. There are many more well-designed studies which consistently show the clinical benefits patients with elevated cholesterol levels can derive from taking statins.

With more recent clinical trials, statin benefits were expanded to those with normal or just average cholesterol levels, especially in high-risk patients such as those already with diabetes or established heart disease. Clinical benefits in terms of reduction of heart attack, stroke and heart-related deaths were shown in those taking statins religiously for at least three years. Heart experts now recommend statin use in high-risk patients indefinitely, possibly for life.

Statins do have side-effects and of most concern for the lay person, is the effect on the liver. Statins work within the liver and infrequently cause a mild hepatitis. Between one and three out of a hundred individuals who start taking a statin type of drug will have a mild elevation in their liver enzymes. Thus, the liver enzymes need to be monitored with the initiation of the drug, and health experts recommend checking the liver enzymes in one month, then three months, and yearly thereafter.

Some have unwarranted fears that statins may have serious complications on the liver when taken for prolonged periods of time. Based on all the studies conducted on statins, a serious liver complication is exceedingly rare, much less than one in 5,000. This has prompted some researchers to say that statins are safer than aspirin and that they should be released for over-the-counter use. Such, however, may not be advisable at this point since the doctor knows best the type of patients suitable for statin use.

What is clear though is that statins are reasonably safe and very effective drugs, and are one of medicine’s more powerful tools in preventing a heart attack or stroke. Hence, many medical experts call them the "super aspirins." In general, statins are well-tolerated.

Recently, statins were seen to have an effect in preventing heart attacks that is independent of its LDL-lowering effect. These are called pleiotropic effects. What is absolutely clear is anyone who has established atherosclerosis, or had a heart attack or stroke and has an LDL above 130 mg percent should clearly be on statin treatment. Their target LDL should be well below 100.

There are some researchers who advocate treating all individuals who have any clinical condition due to atherosclerosis with a statin regardless of their LDL cholesterol, invoking the pleiotropic effects of statins on the atherosclerotic process. Studies consistently show that the lower the LDL, the lower the event rates of atherosclerosis.

Statins are very similar to antihypertensive drugs in that once they are stopped, the cholesterol levels increase to what they were prior to taking them. Stopping statin drugs should only be done because of toxicity or serious side-effects and upon the advice of a physician.

Whether one statin is superior to the other is another subject of controversy. What is regarded as important is the scientific documentation of its clinical benefits. Simvastatin is one of the most extensively documented statins. The recent Heart Protection Study or HPS has shown that simvastatin can produce substantial benefit in a very much wider range of high-risk people than had been thought.

HPS lead investigator Professor Rory Collins said, "These new findings are relevant to the treatment of some hundreds of millions of people worldwide. If now, as a result, an extra 10 million high-risk people were to go into statin treatment, this would save about 50,000 lives a year – that’s a thousand each week. In addition, this would prevent similar numbers of people from suffering non-fatal heart attacks or strokes."

The key, however, is the religious intake of the statin to achieve the desired benefit. Cost remains a major factor affecting long-term compliance in taking the medicine. Even patients who can very well-afford the more expensive brands are now conscious about the cost-benefit factor of drugs. With the introduction of high-quality bioequivalent medicines such as Therapharma’s simvastatin, it is hoped to significantly achieve a more optimal patient compliance.

Many ask what is the best statin to take. Health experts are one in advising that the best statin to take is the one prescribed by your doctor after weighing all the factors.