Should You Take a Cholesterol-Lowering Drug?
For: Cholesterol Drugs and Vitamins Add Up to a Surprise, March
2002
We don't usually discuss prescription drugs in detail,
but the cholesterol-lowering "statin" drugs deserve special
attention, particularly because many healthy people take them as
a preventive against heart disease. These are some of the most widely
prescribed drugs in the world, and for good reason. They have undoubtedly
saved thousands of lives, with fewer side effects than older anti-cholesterol
drugs. And some recent studies have suggested that statin drugs
also have other health benefits.
There are six of these drugs, all ending in "statin":
atorvastatin (brand name Lipitor), simvastatin (Zocor), lovastatin
(Mevacor), pravastatin (Pravachol), cerivastatin (Baycol), and fluvastatin
(Lescol). There's also a "natural dietary supplement"
called Cholestin that contains statin compounds.
Here are some questions and answers.
What do these drugs do?
They reduce the risk of coronary artery disease (CAD)
in a number of ways. Their main effect is to reduce the amount of
cholesterol produced by the liver and clear some of the LDL ("bad")
cholesterol circulating in the blood, thus reducing atherosclerosis
and the risk of a heart attack. (Your body makes most of its cholesterol;
this process is influenced by the amount of cholesterol you eat,
but even more by the saturated fat in your diet.) Some statins may
also raise HDL ("good") cholesterol. In addition, statins
may help protect against CAD by reducing the oxidation of LDL cholesterol
and the inflammatory process in coronary plaques.
What are the statins' other benefits?
At least three recent studies have suggested that
statins reduce the risk of fractures from osteoporosis. Other studies
have found that the drugs modestly lower the risk of stroke in some
people. A study published in October found that some statins may
reduce the risk of Alzheimer's disease. However, all this is far
less certain than the heart-protecting effects. More research is
needed before statins can be recommended for any of these other
disorders.
Who should take statin drugs?
For people with "high" total cholesterol
(240 mg/dl and above), and especially with "high" LDL
(160 and above), who can't lower it via a low-fat diet, weight reduction,
and exercise, statins are usually the drugs of choice. Bear in mind
that your total cholesterol matters less than your LDL and HDL levels.
If your HDL is high, for example, it may help compensate for high
LDL and elevated total cholesterol. Low HDL is a major concern.
In addition, an important 1998 study of 6,600 people
(mostly men) in Texas found that statins can also help prevent heart
attacks among those with "borderline-high" cholesterol
(200 to 239) and LDL (130 to 159)—and possibly even among those
with "desirable" cholesterol levels. After five years,
no matter what their total cholesterol levels at the start of the
study (anywhere from 180 to 264), participants taking a statin not
only had lower cholesterol levels, but also reduced their risk of
heart attack or angina by more than one-third.
If you have borderline-high total or LDL cholesterol
and can't lower it via life-style changes, you should discuss statin
drugs and your other options with your doctor, especially if you
fall into any of these risk categories:
• you're a man over 45, or a woman over 55 not on hormones.
• your HDL is below 35 (some experts believe that the cutoff point for women should be 45).
• you have high blood pressure or diabetes.
• a close relative had premature heart disease (before age 55 for a man, 65 for a woman).
• you smoke (in which case the most important thing by far is for you to quit).
• you are sedentary.
• you are overweight.
• you have a poor diet—too high in saturated fat and cholesterol, too low in fruits, vegetables, and whole grains.
Why shouldn't all adults take statins then?
Few people want to take medication for the rest of their lives. Statin drugs are expensive—$1,000 to $1,800 a year. While they seem to be safe, statins can cause minor side effects, such as gastrointestinal upset, as well as sleep problems and rashes. Rarely, statins can cause severe muscle and liver damage (these almost always go away when the drug is stopped). In addition, no one really knows how safe they are when taken for more than 10 years, particularly if you also take other drugs, as many older people do.
What about Cholestin?
The only advantage of this dietary supplement is that it is much cheaper than the prescription drugs. It's a variety of red yeast derived from fermented rice and contains statin compounds, so it does lower cholesterol, though its effect is less predictable because it also contains other substances. The FDA is fighting in court to have it regulated as a drug (we agree with that move). As with prescription statins, you should not take Cholestin without medical supervision and need to have periodic blood tests to make sure it is working and there are no serious side effects. Just because Cholestin is "natural," that doesn't mean it's harmless. For more on Cholestin, see WELLNESS LETTER, April 1998.
Bottom line
Your first step is to have your cholesterol measured
after a 12-hour fast in order to get a complete picture, including
your LDL and HDL levels. If your cholesterol is high, there is no
substitute for a healthy diet, regular exercise, weight control,
and not smoking, which are still the most important measures in
reducing your risk of heart disease, even if you're taking cholesterol-lowering
medication. If diet and exercise don't lower your cholesterol enough,
discuss your options with your doctor—including other types
of cholesterol-lowering drugs. (The WELLNESS LETTER discussed one
of these, niacin, in December
2000.)
UC Berkeley Wellness Letter, February 2001
