Why are we still in the middle of a ‘statins war’?
April 3, 2019
This article, originally published in 2016, was updated April 3, 2019.
A long-simmering medical debate over a class of drugs used to lower cholesterol burst into the media spotlight across the pond in September 2016. Two British medical journals had accused each other of putting the public’s health in danger. British tabloid the Daily Mail called it the “statins war.”
Nearly three years later, controversy continues to swirl around this often misunderstood but highly effective class of medication.
A study published in the March 2019 Journal of the American Heart Association reported that more than half of patients eligible for statins do not receive them. A majority of those people cited the primary reason as their physicians never offered it.
That’s an amazing figure considering statins are the “gold standard” when it comes to treating high cholesterol, which we explained in our February 2016 article "10 truths about statins and high cholesterol."
I don’t think anyone doubts statins save lives. So what’s the debate? The controversy mainly focuses on two topics:
- Who should receive statins?
- How common and serious are the drugs’ side effects?
"Many people are at low risk for heart attack or stroke and do not need to take a statin. Statins are intended to be used by people at high risk of heart disease."
The controversy in the United Kingdom started in 2013 when the British Medical Journal (BMJ) claimed statins were being overprescribed to people with low risk of heart disease, and that the drugs’ side effects were worse than previously thought.
In September 2016, an article and editorial in The Lancet questioned the BMJ’s claims and accused the journal of causing “measurable harm to public health.” The BMJ responded by asking England’s chief medical officer to create an independent review of the evidence for statins. (It should be noted that doctors in Europe prescribe statins based on different parameters than doctors in the United States.)
In the 2019 study conducted at the Duke Clinical Research Institute, researchers surveyed 5,693 people from the Patient and Provider Assessment of Lipid Management Registry. A total of 1,511 patients were not receiving statin therapy despite meeting eligibility requirements, and 59 percent of those people said they didn’t take the medication because it was never offered to them.
Only 10 percent declined statins, with most citing side effects as their main concern.
Despite these prolonged and often misguided debates, we know the benefits of taking a statin are enormous and largely invisible for people at high risk for heart disease. You don’t see the benefit because it’s the lack of something terrible – such as a heart attack or stroke. Unfortunately, too many people focus on the exaggerated, small risks associated with these life-saving drugs.
Related reading: Medical misinformation: Vet the message!
Before conflicting studies and internet myths scare you away, let’s take a look at how we prescribe statins and their potential side effects.
Who should be prescribed a statin?
Many people are at low risk for heart attack or stroke and do not need to take a statin. Statins are intended to be used by people at high risk of heart disease. They are the ones who derive significant benefit. Use the American Heart Association’s heart disease risk calculator to start a conversation with your doctor about your personal risk.
For years, we prescribed statins such as atorvastatin (Lipitor) and rosuvastatin (Crestor) almost solely based on a target cholesterol level. We would adjust a patient’s medication until we reached a specific number.
In 2013, a joint task force of the American College of Cardiology and the American Heart Association released guidelines for treating cholesterol. These guidelines focused on treating the patient based on his or her risk of developing heart disease, not a target number. The guidelines, which were updated in November 2018 and published in the journal Circulation, now emphasize a balance between LDL numbers and assessing cardiovascular disease. For drug therapy, statins remain the first-line of defense for patients who are at high risk for a cardiovascular event.
There are four general categories recommended to determine who is at high risk for a cardiovascular event, such as a heart attack or stroke. We determine whether people:
- Have clinical atherosclerotic cardiovascular disease (ASCVD), including those with a personal history of stroke, heart attack, or peripheral vascular disease, and also those who suffer from chest pain (angina)
- Have extreme elevations in cholesterol (an LDL cholesterol of 190 mg/dL or higher)
- Are age 40 to 75 and have diabetes
- Are age 40 to 75 and have an estimated 10-year risk of an ASCVD event greater than 7.5 percent
These are good recommendations in general. But they did generate some controversy, specifically when it came to calculating a patient’s 10-year risk. The risk for heart disease increases as we age and almost everyone’s risk for ASCVD is greater than 7.5 percent by age 65. The risk assessment calculator used in the 2013 guidelines is still recommended in the 2018 cholesterol guidelines, but they also recommend that clinicians talk to patients about factors that can increase their chances of heart disease and stroke, including smoking, weight, high blood sugar, and hypertension, as well as family history.
Does this mean everyone 65 and older should be on a statin? Most doctors would say no. In those cases, we need to take into account other heart health risks when deciding whether to prescribe a statin.
Our first step in preventing or treating high cholesterol is with diet and lifestyle changes. We know these changes can be difficult to make, but statin therapy is not an alternative to healthy eating and exercise. Instead, it’s an added preventive measure.
How common are the side effects of statins?
As with all drugs, statins carry a risk of side effects. The most common is muscle ache or pain. About 10 percent of people on a statin will develop this, although it is usually fairly mild, and it is entirely reversible — without causing damage to the muscle — when the drug is discontinued. In 1 out of 10,000 cases, a patient on a statin will develop serious pain and muscle damage. This is so rare that I’ve never seen it in a patient.
Typically, we can eliminate the muscle aches by changing the dose of the statin or switching to a different statin, as the molecular structures of statin medications can be quite different. We usually can find one a patient can tolerate well without side effects.
Other side effects can include increased risk for diabetes and liver damage, but these are also quite rare.
Overcoming the myths surrounding statins
People believe in science when they get in their car, board an airplane, or use their smartphone. They believe in aerospace and electronic engineering, but some are suspicious of biomedical sciences. It’s time we clear the air once and for all.
Another belief held by some that I find puzzling is the notion that physicians have a personal financial interest in giving their patient a statin (or other drug). Whereas I cannot say definitively that this never happens, it is rare indeed. The very great majority of physicians work hard to do what’s best for their patients, relying on the latest science to plan a course of treatment.
Our goal is to decrease your risk of heart disease, heart attack, and stroke. We know that for patients at high risk, statins can do this — and potentially save lives. Before you refuse to take a statin or stop taking a statin, consult your doctor. He or she can explain why you may benefit from the drug or help you find a different statin if you experience side effects.
We are constantly evaluating current methods for preventing and treating medical conditions. In the medical field, it’s important to continually seek better or safer options. But I hope the debates playing out in the media and in online forums will not keep doctors from prescribing statins, or keep patients who truly need statins from taking them.