THE NEW YORK TIMES
24 March, 2019
NEW YORK — My column last April “Pros and Cons of Statin Therapy” has elicited nearly 700 online comments, many of them from people who accused me of selling out to Big Pharma.
Yes, statins are blockbuster drugs with sales in the billions, but some people question if they’re safe and effective. In this column, I will try yet again to explain my understanding of statins and help others deal sensibly with these potentially lifesaving drugs.
I do not own stock in any drug company, and no friend or relative works for one. My personal decisions and published statements about any medication are based on a thorough analysis of the best available medical evidence. Those decisions and statements may change if and when reliable new findings warrant. This is science, after all, and science is constantly evolving.
As I mentioned in last year’s column, I had taken a monthslong hiatus after more than a decade on a statin to see if it would relieve my periodic back pain. It did not. What it did do was allow my cholesterol level to soar back to a total of 248 milligrams per decilitre of blood and an LDL (the heart-damaging lipid) level of 171, 70-plus milligrams higher than it should be.
My decision to take a statin was not made casually. I first tried a stricter-than-usual diet of home-cooked meals rich in vegetables and fish and nearly devoid of saturated fats, processed foods and refined carbs and sugars. I took supplements of fish oils, fibre and plant sterols, among other non-prescription products said to lower cholesterol. And, of course, I kept my weight down and activity up — a daily regimen of walking, swimming and cycling. All, alas, to no avail.
My doctor deduced that my body was manufacturing too much cholesterol, and knowing I had a frightening family history of premature heart attacks, he thought I’d be wise to take a statin.
Many of the readers who responded to my April column also said that statins caused unrelenting muscle pain that resolved once they stopped taking the drug. I don’t dispute that this can happen to some people, even though numerous studies, including a double-blind placebo-controlled trial, indicated that most reported muscle aches were not attributable to statins.
In addition, in about 9 per cent of patients, statins have been shown to raise the risk of developing Type 2 diabetes.
Knowing the odds of side effects and making sure to get periodic check-ups that would pick up an adverse reaction, I chose to focus on the drugs’ potential benefits. Most important to me is that for each 40-milligram drop in heart-damaging LDL on a statin, the risk of a major cardiovascular event drops by 25 per cent each year.
In a 20-year study in Britain of men who had no coronary risk factors other than high LDL levels and no evidence of heart disease, 40 milligrams a day of pravastatin (Pravachol), a relatively weak statin, reduced coronary deaths by 28 per cent.
Also important are the likely mechanisms behind such protection. In addition to lowering blood levels of LDL, statins reduce inflammation, now recognised as an important risk factor for heart disease, and they stabilise the plaque that narrows coronary arteries. Most heart attacks happen when a chunk of plaque becomes unstable, breaks loose and obstructs a major artery feeding the heart.
There may be other important benefits. A review of 36 studies involving more than 3.2 million people found that statin use reduced the risk of blood clots in a limb or lung by 15 to 25 per cent. Also enticing is the finding among 400,000 men and women on Medicare linking statin use to a lower risk of developing Alzheimer’s disease. To be sure, this is just an association, not a controlled clinical trial, but one possible explanation for the link is that cholesterol plays a role in processing beta-amyloid, plaques of which are a hallmark of Alzheimer’s.
None of this means that every adult over 50 should be on a statin. Trials involving hundreds of participants with differing cholesterol levels and coronary risk factors have shown that those who are at the low end of the risk profile are unlikely to benefit, at least in terms of cardiovascular disease.
Currently, doctors and patients can use the Cardiovascular Risk Calculator to determine where on the risk spectrum someone between the ages of 40 and 75 falls. Those calculated to face a risk of experiencing a cardiovascular event over the next 10 years below 5 per cent are considered low risk; a risk level between 5 per cent and 7.4 per cent is labelled borderline; a level of 7.5 per cent to 19.9 per cent is intermediate, and a level of 20 per cent or higher is considered high.
In the latest guidelines from an expert committee of cardiologists, high-risk patients — including anyone who has already had a cardiovascular event — should be advised to start taking a statin with the goal of lowering their cholesterol level by more than 50 per cent. The goal for intermediate-risk patients is a 30 per cent reduction in their LDL-cholesterol level.
Those who are uncertain about the extent of their risk or who hesitate to take a statin based only on a medical profile suggesting their cardiovascular risk is relatively high could opt for a CT scan of the heart to determine their coronary artery calcium score. The score indicates how much hardened plaque may line the arteries critical to their heart’s health.
Also, for those facing a higher-than-average risk of suffering a heart attack or stroke, the first step in reducing that risk is not a drug but getting modifiable risk factors under control. Even if you plan to take a statin, the drug will be most effective when combined with measures that reduce cardiovascular risk.
That means adopting and sticking to a Mediterranean-style diet that emphasises fruits, vegetables, peas, beans, nuts and seeds and contains little or no saturated fats, the fats found in meats, poultry and dairy products that are not fat-free. Substitute whole grains for refined ones. The best oils to use for cooking and salads are olive, canola, grapeseed and avocado.
Control of body weight, high blood pressure and elevated blood sugar are also critically important. Again, the first step is consuming the kind of diet outlined above, using less salt and other sources of sodium, and eating fewer sweets and refined carbohydrates like white rice and white bread.
If, unlike me, you’re lucky, such changes may even lower your cholesterol enough to eliminate the need for a statin and concern about possible side effects.
NEW YORK — My column last April “Pros and Cons of Statin Therapy” has elicited nearly 700 online comments, many of them from people who accused me of selling out to Big Pharma.
Yes, statins are blockbuster drugs with sales in the billions, but some people question if they’re safe and effective. In this column, I will try yet again to explain my understanding of statins and help others deal sensibly with these potentially lifesaving drugs.
I do not own stock in any drug company, and no friend or relative works for one. My personal decisions and published statements about any medication are based on a thorough analysis of the best available medical evidence. Those decisions and statements may change if and when reliable new findings warrant. This is science, after all, and science is constantly evolving.
As I mentioned in last year’s column, I had taken a monthslong hiatus after more than a decade on a statin to see if it would relieve my periodic back pain. It did not. What it did do was allow my cholesterol level to soar back to a total of 248 milligrams per decilitre of blood and an LDL (the heart-damaging lipid) level of 171, 70-plus milligrams higher than it should be.
My decision to take a statin was not made casually. I first tried a stricter-than-usual diet of home-cooked meals rich in vegetables and fish and nearly devoid of saturated fats, processed foods and refined carbs and sugars. I took supplements of fish oils, fibre and plant sterols, among other non-prescription products said to lower cholesterol. And, of course, I kept my weight down and activity up — a daily regimen of walking, swimming and cycling. All, alas, to no avail.
My doctor deduced that my body was manufacturing too much cholesterol, and knowing I had a frightening family history of premature heart attacks, he thought I’d be wise to take a statin.
Many of the readers who responded to my April column also said that statins caused unrelenting muscle pain that resolved once they stopped taking the drug. I don’t dispute that this can happen to some people, even though numerous studies, including a double-blind placebo-controlled trial, indicated that most reported muscle aches were not attributable to statins.
In addition, in about 9 per cent of patients, statins have been shown to raise the risk of developing Type 2 diabetes.
Knowing the odds of side effects and making sure to get periodic check-ups that would pick up an adverse reaction, I chose to focus on the drugs’ potential benefits. Most important to me is that for each 40-milligram drop in heart-damaging LDL on a statin, the risk of a major cardiovascular event drops by 25 per cent each year.
In a 20-year study in Britain of men who had no coronary risk factors other than high LDL levels and no evidence of heart disease, 40 milligrams a day of pravastatin (Pravachol), a relatively weak statin, reduced coronary deaths by 28 per cent.
Also important are the likely mechanisms behind such protection. In addition to lowering blood levels of LDL, statins reduce inflammation, now recognised as an important risk factor for heart disease, and they stabilise the plaque that narrows coronary arteries. Most heart attacks happen when a chunk of plaque becomes unstable, breaks loose and obstructs a major artery feeding the heart.
There may be other important benefits. A review of 36 studies involving more than 3.2 million people found that statin use reduced the risk of blood clots in a limb or lung by 15 to 25 per cent. Also enticing is the finding among 400,000 men and women on Medicare linking statin use to a lower risk of developing Alzheimer’s disease. To be sure, this is just an association, not a controlled clinical trial, but one possible explanation for the link is that cholesterol plays a role in processing beta-amyloid, plaques of which are a hallmark of Alzheimer’s.
None of this means that every adult over 50 should be on a statin. Trials involving hundreds of participants with differing cholesterol levels and coronary risk factors have shown that those who are at the low end of the risk profile are unlikely to benefit, at least in terms of cardiovascular disease.
Currently, doctors and patients can use the Cardiovascular Risk Calculator to determine where on the risk spectrum someone between the ages of 40 and 75 falls. Those calculated to face a risk of experiencing a cardiovascular event over the next 10 years below 5 per cent are considered low risk; a risk level between 5 per cent and 7.4 per cent is labelled borderline; a level of 7.5 per cent to 19.9 per cent is intermediate, and a level of 20 per cent or higher is considered high.
In the latest guidelines from an expert committee of cardiologists, high-risk patients — including anyone who has already had a cardiovascular event — should be advised to start taking a statin with the goal of lowering their cholesterol level by more than 50 per cent. The goal for intermediate-risk patients is a 30 per cent reduction in their LDL-cholesterol level.
Those who are uncertain about the extent of their risk or who hesitate to take a statin based only on a medical profile suggesting their cardiovascular risk is relatively high could opt for a CT scan of the heart to determine their coronary artery calcium score. The score indicates how much hardened plaque may line the arteries critical to their heart’s health.
Also, for those facing a higher-than-average risk of suffering a heart attack or stroke, the first step in reducing that risk is not a drug but getting modifiable risk factors under control. Even if you plan to take a statin, the drug will be most effective when combined with measures that reduce cardiovascular risk.
That means adopting and sticking to a Mediterranean-style diet that emphasises fruits, vegetables, peas, beans, nuts and seeds and contains little or no saturated fats, the fats found in meats, poultry and dairy products that are not fat-free. Substitute whole grains for refined ones. The best oils to use for cooking and salads are olive, canola, grapeseed and avocado.
Control of body weight, high blood pressure and elevated blood sugar are also critically important. Again, the first step is consuming the kind of diet outlined above, using less salt and other sources of sodium, and eating fewer sweets and refined carbohydrates like white rice and white bread.
If, unlike me, you’re lucky, such changes may even lower your cholesterol enough to eliminate the need for a statin and concern about possible side effects.
THE NEW YORK TIMES
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