Statins review – The Good, the Bad and the Ugly

What are Statins?

Statins are the ‘top of the pops’. They are like the Beatles in 1966. They are the most prescribed drugs in Australia. Even the second most prescribed drug is a different type of Statin medication. These drugs are not at the top of the most prescribed drug, they are the top of the list. They must be lifesaving! They make you feel wonderful! Where can I get some?

Statins clearly perform the following biochemistry in the body. they:

• Lower total cholesterol levels.
• Specifically lower ‘bad’ LDL (Low Density Lipoprotein) cholesterol.
• Raise the ‘good’ HDL (High Density Lipoprotein) cholesterol.
• Lower blood fats (Triglycerides).

Now that is a pretty impressive resume. But is it all good?

The History of the Statin

During the 1950s, the pathway of cholesterol synthesis had been fully revealed, and the rate-limiting step had been shown to be the transformation of β-hydroxy-β-methyl glutaryl-CoA (HMG-CoA) to mevalonate. The rate-limiting enzyme HMG-CoA reductase caught the interest of the Japanese biochemist Endo who hypothesized that certain fungi suppressed HMG-CoA reductase, possibly as a defence mechanism against other microbes. At the Fermentation Research Laboratories of Sankyo in Tokyo, he searched for a suitable fungus among 6000 fermentation broths during 2 years. Together with Masao Kuroda, he finally detected that the fungus Pythium ultimum produced citrinin that turned out to inhibit HMG-CoA reductase and was a relatively strong inhibitor of cholesterol synthesis in rats. Good news for rats eh!

Fast forward a few years Brown and Goldstein detected the LDL receptor and the strong connection between HMG-CoA reductase activity and the functioning of the receptor, a discovery that won them the Nobel Prize in 1985. It was soon thereafter shown that the HMG-CoA reductase inhibition increased messenger RNA for LDL receptors in the liver and increase the density of LDL receptors on the surface of liver cells. Soon after this, Merck synthesised and patented the first statin medication.

Statins – The Good

Since these early days, several large-scale clinical trials have demonstrated the safety and efficacy of Statins in reducing cardiovascular events in people with existing heart disease. The Cholesterol Treatment Trialists Collaboration conducted a meta-analysis of five randomized trials of Statins that compared more intensive (higher dose or more powerful Statin) and less intensive (lower dose or less powerful Statin) regimens in 39,612 patients with coronary artery disease (CAD). Intensive Statin treatment was associated with a greater reduction in major vascular events compared with less intensive therapy. All of this data has updated the clinical guidelines of the European Society of Cardiology, the American College of Cardiology/American Heart Association, the Japanese Cardiology Society, and the Japan Atherosclerosis Society. So far so good.

Statins – The Bad

In a lot of cases, Statins are prescribed for people who feel fine, but a routine blood test reveals that your cholesterol levels are high. So, the well-meaning GP prescribes you a Statin drug, based solely on your blood results with the aim of preventing the heart attack coming your way. Again, you feel fine but you take the medication because your doctor knows best and you don’t really want to get the heart attack coming your way. Plus, your granddad/grandma had a heart attack and you have heard about this disease running in the family.
So, you take the pill but you don’t feel right. In fact, your muscles ache and you are in pain. You can’t work out like you used to and your energy levels are down. You go back to tell your doctor these symptoms and he/she says that this is a common side effect to the medication. In fact, up to 3 in 10 people who take this medication report the same symptoms. It is not the end of the world but what do you do? Continue taking the pill, with the side effects or, bin it?

Statin side effects

• Muscle pain
• Nerve pain
• Joint pain
• Depression and mood swings
• Cognitive decline
• Fatigue
• Increase risk of diabetes
• Dizziness
• Headaches
• Liver and kidney damage
• Weakness

The Science of Statins

What do the scientific studies say for people in your predicament? Should you be taking a Statin to prevent a heart attack that you haven’t had yet? In May 2017, a large study was published to see whether taking a Statin is useful for the prevention of a heart attack. After all, if Statin’s help to prevent the biggest killer, shouldn’t we all be taking it? The study concluded by saying that there was no benefit to taking a Statin (Pravastatin) for primary prevention to older adults with moderate high cholesterol and hypertension. Worse than that is that there was a non-significant direction toward increased all-cause mortality with Pravastatin if you were aged 75 or older, meaning you may have a slightly increased risk of dying if you are taking the Statin.

The Choice

Considering you felt fine before taking the medication and you should feel better going off the medication, you decide to bin the pills and get on with life. You think, after all, why is it worth living a life where you are in pain all day and you feel weak and fatigued? Remember, you are only taking this medication to treat a number and not because you had only weeks to live; and reports in recent scientific papers don’t help persuade you to take your Statin. One paper stated that “the big companies have a stake in the Statin market and many have funded research reinforcing their efficacy and safety, which has caused unease. ”

The Ugly

Unfortunately, Statins have been shown to be ineffective for the prevention of cardiovascular disease and may even be harmful to take them if you are over 75 years old. But can they even be harmful? The answer is yes. A recent study again published in May 2017 which pooled 20 different studies and quantified the increase risks of developing type II diabetes, which carries with it risks such as blindness, loss of limbs, reduced quality of life and a reduced life span. The study found that there is a 44% increased risk of developing diabetes when compared to non-Statin users. Remember, this is not just one study, this pools the results of 20 studies.

 

Figure 1. The mechanisms show Statin medications increase the risk of diabetes.

The Defense of the Doctor

Given this pretty conclusive evidence, the question must be asked: why is this drug the number one and number two prescribed drugs in Australia? Why are doctors commonly subscribing powerful drugs to people that feel fine? No one is suggesting doctors are unintelligent people. They are highly trained and nearly all are doing what is best for your health. The answer to this complex question is twofold:
1. You doctor may be unaware of these recent studies. After all this is pretty new information and Statins have been prescribed for around 30 years.
2. Your doctor is aware of these risks and side effects and has judged in their professional opinion that the risks of heart disease for you outweigh the side effects.
Either way, if you are currently taking statin medications do not stop taking them before discussing issues with your doctor.

The Bottom Line

Statins have been prescribed for decades. There is clear evidence they reduce LDL cholesterol, triglycerides while increasing HDL cholesterol levels better than most other medications. Most people don’t get obvious side effects. Having said that it is worth discussing healthier options with your doctor like exercising and eating better, both of which have been proved to improve your cardiovascular health, overall health and have a range of other health benefits.
Make sure you are not at a higher risk of developing diabetes. If you are unsure about this, discuss these risks with your GP so you can make an informed choice about taking Statins.