Statins: Are these cholesterol-lowering drugs right for you?

Statins are drugs that can lower your cholesterol. They work by blocking a substance your body needs to make cholesterol. Statins may also help your body reabsorb cholesterol that has built up in plaques on your artery walls, preventing further blockage in your blood vessels and heart attacks.

Statins include well-known medications such as atorvastatin (Lipitor), simvastatin (Zocor), lovastatin (Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and others. Lower cost generic versions of many statin medications are available.

Already shown to be effective in lowering cholesterol, statins may have other potential benefits. But doctors are far from knowing everything about statins. Are they right for everybody with high cholesterol? What happens when you take a statin for decades? Can statins help prevent other diseases?

Should you be on a statin?

Whether you need to be on a statin depends on your cholesterol level along with your other risk factors for cardiovascular disease.

High cholesterol
If you have high cholesterol, meaning your total cholesterol level is 240 milligrams per deciliter, or mg/dL, (6.22 millimoles per liter, or mmol/L) or higher, or your "bad" cholesterol (LDL) level is 130 mg/dL (3.68 mmol/L) or higher, your doctor may recommend you begin to take a statin. But the numbers alone won't tell you or your doctor the whole story.

If the only risk factor you have is high cholesterol, you may not need medication because your risk of heart attack and stroke could otherwise be low. High cholesterol is only one of a number of risk factors for heart attack and stroke.

Other risk factors
Before you're prescribed a statin, your cholesterol level is considered along with other risk factors for cardiovascular disease, including:

• Family history of high cholesterol or cardiovascular disease
• Inactive (sedentary) lifestyle
• High blood pressure
• Age older than 55 if you're a man, or older than 65 if you're a woman
• Poor general health
• Having diabetes
• Overweight or obesity
• Smoking
• Narrowing of the arteries in your neck, arms or legs (peripheral artery disease)

If your doctor decides you should take a statin, you and your doctor will have to decide what dose to take. Statins come in varied doses — from as low as 5 milligrams to as much as 80 milligrams, depending on the medication. If you need to decrease your LDL cholesterol significantly — by 50 percent or more — it's likely you'll be prescribed a higher dose of statins. If your LDL cholesterol isn't as high, you'll likely need a lower dose. Talk to your doctor if you have concerns about the amount of statins you're taking.

Lifestyle is still key for lowering cholesterol

Lifestyle changes are essential for reducing your risk of heart disease, whether you take a statin or not. Lifestyle changes you should consider making include:

• Quitting smoking
• Eating a healthy diet that's low in fat, cholesterol and salt
• Exercising 30 minutes a day on most days of the week
• Managing stress

If you're following the recommended lifestyle behaviors but your cholesterol — particularly your low-density lipoprotein (LDL, or "bad") cholesterol — remains high, statins might be an option for you. Risk factors for heart disease and stroke are:

• High cholesterol
• High blood pressure
• Diabetes
• Being overweight or obese
• Family history of heart disease
• Not exercising
• Heavy alcohol use
• Poor stress and anger management
• Older age
• Smoking
• Narrowing of the arteries in your neck, arms or legs (peripheral artery disease)

Consider statins a lifelong commitment

You may think that once your cholesterol goes down, you can stop taking medication. But, if your cholesterol levels have decreased after you take a statin, you'll likely need to stay on it indefinitely. If you stop taking it, your cholesterol levels will probably go back up.

The exception may be if you make significant changes to your diet or lose a lot of weight. Substantial lifestyle changes may help you lower your cholesterol without continuing to take the medication, but don't make any changes to your lifestyle or medications without talking to your doctor first.

The side effects of statins

Although statins are well tolerated by most people, they do have side effects, some of which may go away as your body adjusts to the medication.

Common, less serious side effects

• Muscle and joint aches (most common)
• Nausea
• Diarrhea
• Constipation

Potentially serious side effects

• Liver damage. Occasionally, statin use causes an increase in liver enzymes. If the increase is only mild, you can continue to take the drug. If the increase is severe, you may need to stop taking it, which usually reverses the problem. If left unchecked, increased liver enzymes can lead to permanent liver damage. Certain other cholesterol-lowering drugs, such as gemfibrozil (Lopid) and niacin, increase the risk of liver problems even more in people who take statins. Because liver problems may develop without symptoms, people who take statins have a blood test six weeks after starting a statin medication to check their liver function. After that, your doctor may recommend yearly blood tests.
• Muscle problems. Statins may cause muscle pain and tenderness (statin myopathy). The higher the dose of statin you take, the more likely you are to have muscle pains. In severe cases, muscle cells can break down (rhabdomyolysis) and release a protein called myoglobin into the bloodstream. Myoglobin can damage your kidneys. Certain drugs when taken with statins can increase the risk of rhabdomyolysis. These include gemfibrozil, erythromycin (Erythrocin), antifungal medications, nefazodone, cyclosporine and niacin. If you take statins and have new muscle aching or tenderness, check with your doctor.

It's important to consider the effects of statins on other organs in your body, especially if you have health problems such as liver or kidney disease. Also, check whether statins interact with any other prescription or over-the-counter drugs or supplements you take.

Keep in mind that when you begin to take a statin, you'll most likely be on it for the rest of your life. Side effects are often minor, but if you experience them, you may want to talk to your doctor about decreasing your dose or trying a different statin. Don't stop taking a statin without talking to your doctor first.

Are there other options?

Statins effectively reduce "bad" cholesterol (LDL). But, because of genetic differences, the type or dose of statin or combination of statins with other cholesterol-lowering drugs each person takes can vary. For example:

• If you are not able to lower your LDL to the desired goal using statin medication, your doctor may add ezetimibe (Zetia) to your treatment plan or switch to a combination ezetimibe and simvastatin medication (Vytorin). This combination will help drop your LDL level further, perhaps even another 15 to 20 percent.
• If you have both high LDL and high triglycerides, you may benefit from combining the statin with prescription niacin (Niaspan, Niacor) or combining the statin with a fibric acid drug such as fenofibrate (TriCor) or gemfibrozil (Lopid). The risk of muscle problems is higher when these medications are paired, so your dose of statins may be lowered to less than 20 milligrams (mg).
• If you have just high triglycerides, use of niacin (Niaspan, Niacor) is very effective. Fibric acid agents (TriCor and Lopid) are another option. Fish oil (omega-3 fatty acid) supplements (Lovaza) in 2- to 4-gram doses also can help.
• If your high-density lipoprotein (HDL) cholesterol is low, niacin might be the best choice to raise it. Fibric acids also are useful but less effective than niacin. Exercise and weight loss may help, as well.
• If your doctor recommends niacin in addition to a statin, you might want to discuss taking a medication that combines both niacin and a statin, such as Simcor or Advicor. These medications can reduce the number of pills you have to take. However, that may be the only benefit. Research hasn't shown that the combination drugs lower cholesterol more than does taking niacin and a statin separately.

What if taking a statin doesn't lower your cholesterol?

If a statin doesn't help lower your cholesterol, your doctor may first suggest trying a different statin or increasing the dose of the statin you currently take. In some cases, one medication may simply not be effective and a different drug must be substituted.

Your doctor may also add other medications, or may suggest that you make more lifestyle changes to help lower your cholesterol.

What other benefits do statins have?

Researchers think statins may have benefits other than just lowering your cholesterol. One promising benefit of statins appears to be their anti-inflammatory properties, which help stabilize the lining of blood vessels. This has potentially far-reaching effects, from the brain and heart, to blood vessels and organs throughout the body.

In the heart, stabilizing the blood vessel linings would make plaques less likely to rupture, thereby reducing the chance of a heart attack. Statins also help relax blood vessels, lowering blood pressure. In addition, statins could reduce your risk of blood clots. For these reasons, doctors are now beginning to prescribe statins before and after coronary artery bypass surgery or angioplasty, and following certain types of strokes.

Statins could also have benefits that help prevent diseases that aren't related to your heart health, although more research is necessary. Other benefits of statins could include a reduced risk of:

• Arthritis and bone fractures
• Some forms of cancer
• Dementia and Alzheimer's disease
• Kidney disease

Statins may also be helpful in controlling the body's immune system response after an organ transplant.

Weighing the risks and benefits of statins

When thinking about whether you should take statins for high cholesterol, ask yourself these questions:

• Do I have other risk factors for cardiovascular disease?
• Am I willing and able to make lifestyle changes to improve my health?
• Am I concerned about taking a pill every day, perhaps for the rest of my life?
• Am I concerned about statins' side effects or interactions with other drugs?

It's important to take into account not only your medical reasons for a decision, but also your personal values and concerns. Talk to your doctor about your total risk of cardiovascular disease and discuss how your lifestyle and preferences play a role in your decision about taking medication for high cholesterol.

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