We have been writing about statin-type cholesterol-lowering drugs for 36 years. Even before the FDA approved lovastatin (Mevacor) on September 1, 1987, we wrote that the drug “demonstrated almost unbelievable power to lower cholesterol levels.” Our initial enthusiasm has been tempered by time and reports by readers of unpleasant statin side effects. A recent statin smackdown has been severely criticized by a cardiologist who believes statins are safe and are saving lots of lives annually.
Initial Statin Enthusiasm Tempered By Time:
On July 31, 1987, we wrote in our nationally syndicated newspaper column:
“The availability of a seemingly quick and easy ‘fix’ for the cholesterol problem could lead to a stampede of people seeking an easy way to lower their heart attack risk. Before the stampede gets started, we caution that all new drugs have one unavoidable risk–they haven’t withstood the test of time, from which we frequently learn so much.
“For the moment, those not up high on the risk scale would be well advised to continue using diet and exercise to attack the cholesterol problem. With time, and experience, we may indeed find that this new drug will enable us to easily manage cholesterol down to a highly safe level for everyone.”
Fast forward nearly four decades. Well over 40 million Americans take a statin daily to prevent heart disease. We have had a lot of time and experience with statins!
Some physicians have joked that we should put drugs like atorvastatin, lovastatin, rosuvastatin or simvastatin in drinking water to keep everyone healthy. Others are concerned about the statin side effects some people experience.
Statin Smackdown Starts Because of Muscle Pain:
A few months ago, we answered a question from a 67-year-old man in good health. He has been a runner for 48 years. A blood test had shown an elevated LDL cholesterol.
The doctor prescribed high-dose atorvastatin (80 mg). This reader wrote:
“After taking this medicine for two months, I started having pain in my glutes and hamstrings. The doctor attributed that to my running. It’s been two months more and my pain persists. I now run (slowly) just one day a week.
“My doctor told me to see a physical therapist for my pain. First, I decided to do a complete review of numbers. These are all indicators that I am at low risk for heart disease. I also passed a stress test and had an echocardiogram that did not show any problems.”
Natural Approaches for Lowering Cholesterol?
This reader wanted to know if there were any natural options that might lower LDL cholesterol without causing muscle pain. We emphasized the importance of maintaining physical activity for overall good health. In addition, we answered his question about a specific supplement (citrus bergamot).
Why Is Exercise Important?
If you ask virtually any health professional what is essential for good health, the answer will come back: “stay active!” Exercise can improve cardiovascular health (Frontiers in Cardiovascular Medicine, June 4, 2019).
It helps control weight, lowers blood pressure, reduces the risk of type 2 diabetes and decreases blood lipid concentrations. It also strengthens bones, improves mood, promotes better sleep and lowers the likelihood of developing dementia.
Why A Statin Smackdown? These Drugs Can Interfere with Exercise:
A key piece of our statin smackdown centered around the idea that statins might interfere with exercise. We did not make that up.
An article in JAMA Internal Medicine (Aug. 17, 2014) reported:
“In this large observational study in older men, we examined the cross-sectional differences and longitudinal changes in physical activity by statin use. Overall, physical activity declined at similar rates to those observed in a prior study. While short-term studies suggest that statins decrease physical activity in older adults for up to one year, it was unclear if this effect was sustained. Our long-term study, that followed men up to an average of 6.9 years, suggests that statins are associated with less physical activity for as long as statins are used.
“The exact mechanism by which statins affect muscles is not known. There are a number of possible causes. For example, statins may disrupt mitochondrial function and interfere with ATP production, contributing to fatigue and muscle weakness. Disruption of mitochondria may also cause myopathy [muscle disease] by increasing the production of reactive oxygen species, inducing DNA damage, and initiating apoptosis [cell death]. Recent studies have also indicated these same mechanisms are precipitated or exacerbated during exercise in statin users. If exercise-induced myopathy occurs in older adults taking statin medications, this may explain why we observed prevalent statin users engaged in less physical activity in this study.”
Why Do Doctors Reject Statin Side Effects?
All drugs have the potential to cause some side effects in some people. That should not be controversial. Yet many cardiologists hate the idea of statin side effects.
A study published in the European Journal of Preventive Cardiology (March, 2014) concluded that symptoms such as arthritis, muscle pain and weakness are not caused by statins:
“Only a small minority of symptoms reported on statins are genuinely due to the statins: almost all would occur just as frequently on placebo. Only development of new-onset diabetes mellitus was significantly higher on statins than placebo; nevertheless only 1 in 5 of new cases were actually caused by statins.”
We suspect that many people do not experience muscle pain and weakness while taking statins. But some are severely affected. If you would like to read more about statins and myopathy and myositis, here is a link with many case reports.
Incensed Cardiologist Responds to Statin Smackdown:
Because we had the temerity to 1) confirm that statins can cause muscle damage and 2) respond to the request from our reader regarding natural ways to lower LDL cholesterol, we received an angry response from a cardiologist. He accused us of giving out bad advice that leads to heart attacks and deaths.
He insisted that we should have responded to the runner with no signs of heart disease this way:
“We are glad that you want to be physically active and that you have a normal stress test. Nonetheless, with your age and your LDL you are at high risk for a coronary event in the next ten years. According to American and European guidelines, you should take a statin. Further diagnostic testing and risk scoring are not recommended.
“The likelihood of a coronary event will be significantly decreased by lowering your LDL. About 90 percent of people can take a statin. You may want to try a different statin or reduce the dose of the one you are taking. Less than 1 percent of people have a serious reaction to statins. Your doctor can do a blood test to see if you are having a serious reaction.
“Other drugs can be used to lower your cholesterol without the muscle side effects of statins. The most powerful other drug is a PCSK9 inhibitor [alirocumab (Praluent) or evolocumab (Repatha)]. The most important thing is to significantly reduce the LDL.
“Your estimated life expectancy is another 19 years. With that time frame in mind, lowering your LDL is a worthwhile investment in your future.”
How We Respond To Statin Smackdown Spanking:
We agree that controlling risk factors for heart disease is worthwhile. There are many additional risks besides LDL cholesterol. They include:
Elevated blood glucose (a possible side effect of statins)
Inflammation or high C-reactive protein levels
Hostility or anger
Elevated lipoprotein (a) levels (aka Lp(a)
High uric acid levels
Hormone replacement therapy with progestin
We wish that some cardiologists would look past LDL cholesterol alone and consider some of these other risk factors for heart disease as well.
A Different Perspective from Another Cardiologist:
The debate over the efficacy of statins to prevent heart disease in healthy people, like the runner who wrote to us, has become highly polarized. The cardiologist who wrote to us is a great believer in guidelines set forth by the American College of Cardiology. It recommends statins for virtually every older person.
Cardiologist Rita Redberg, former Editor-in-Chief of JAMA Internal Medicine has a different perspective:
“When healthy patients without cardiovascular disease are prescribed statins they do not live longer, and they have only a marginal reduction in the risk of ischemic events [heart attacks and strokes]. Furthermore, statins cause numerous side effects which substantially limit their net benefit” (Atherosclerosis, Sept. 2022).
“The vast majority of randomized controlled trials (RCTs) of statins in primary prevention have failed to find statistically significant reductions in overall mortality.”
“Cohort studies, individual RCTs, and meta-analyses have all found that statin therapy increases the risk of developing diabetes. The absolute risk increase for diabetes after four years of statin therapy is 0.39%, which is similar to the absolute risk reduction for MIs [heart attacks] and strokes. This suggests that for every patient in whom an ischemic event is prevented by statins another is likely to be diagnosed with diabetes.”
“Observational studies have found that at least 10–20% of patients on statins report muscle pain. Myalgias are the most common reason patients cite for discontinuing statins, and they contribute to the overall high level of dropout from statin therapy.”
No Statin Smackdown for People with Heart Disease!
People who have diagnosed heart disease clearly benefit from statins. The controversy only involves healthy people who do not have heart disease.
This is especially relevant for older people. Dr. Redberg continued:
“This suggests that the minor reductions in MIs [heart attacks] and ischemic strokes seen in middle aged adults cannot be expected in elderly patients, exposing them to all the harms of statins without any benefits.”
Any decision about cholesterol-lowering treatment should be made in collaboration between the patient and the prescriber. That way questions of lifestyle, other risk factors and age can be considered carefully.
An Alternative to Statins:
The cardiologist who wrote to us recommended alternative drugs if muscle pain is a problem for people taking statins. They are PCSK9 inhibitors such as Praluent or Repatha.
There is another drug that is making headlines. It’s called bempedoic acid (Nexletol). Some heavy-hitter cardiologists published an article in JAMA (June 24, 2023) titled:
“Bempedoic Acid for Primary Prevention of Cardiovascular Events in Statin-Intolerant Patients.”
It demonstrated that people who were at high risk for heart problems and who could not tolerate statins could benefit from Nexletol. If you would like to learn more about this drug, here is a link to an article about the pros and cons of bempedoic acid that we have written. We will bring you up to date on the latest research in our Friday “Health News” newsletter. Stay tuned for updates.
What Do You Think?
A cardiologist has spanked us for reporting on statin side effects, especially muscle pain and weakness. To summarize, he made it clear that he believes “Less than 1% of people have a serious reaction to statins.”
We suspect he is referring to a life-threatening adverse reaction such as rhabdomyolysis (breakdown of muscle tissue). We have heard from a great many readers that they have had other kinds of muscle damage. Although not lethal, this has had an impact upon the quality of their lives.
Although many people do not experience any statin side effects, others complain of cataracts, elevations of blood sugar, muscle damage and cognitive impairment. Please share your statin story (positive or negative) in the comment section below.