Guest post by TeddyDr in support of the current use of statins:
In the recent weeks there has been a flurry of news activity surrounding the class of life-saving cholesterol lowering drugs known as “statins.” (example articles from above here and here) False references, retracted scientific papers, and political drum-beating are all adding to the confusion making it nearly impossible to know what the current, unbiased data show regarding the statins and their risks and benefits.
Before we go any further, let’s make something perfectly clear: all of the many studies that have been published over the years since the first statins were introduced overwhelmingly show that STATINS SAVE LIVES. This is an indisputable (now wrongly disputed, in the press at least) fact. Statins were a game changer for the field of medicine and have single-handedly saved tens of thousands of Americans from suffering the terrible consequences of ischemic heart disease and early death.
How is it that statins go about saving lives? As it turns out, through a very simple mechanism. Statins are small molecules that selectively inhibit the enzyme HMG-CoA reductase. HMG-CoA reductase is an enzyme in the liver that plays a critical role in the liver’s ability to make cholesterol (70% of the cholesterol in our body is made by the liver, with the rest coming from our diet). Therefore, by inhibiting HMG-CoA reductase, statins actively prevent the liver from producing and releasing cholesterol into the blood, where it has been definitively shown to be detrimental to heart and blood vessel health. Since statin treatment prevents it from synthesizing new cholesterol, the liver begins to deplete its own stockpiled cholesterol and actively begins sucking cholesterol out of the blood in an attempt to replenish its stores.. It is through these two synergistic mechanisms that statins so dramatically lower the amount of circulating cholesterol in the blood and prevent the cholesterol from accumulating in the walls of the arteries of our body where it does so much damage. Thus it’s not surprising that studies have proven that statins can reduce the risk of having a cardiac event by more than 60%.
But as with any drug, statins aren’t perfect. So far, they are the best drugs we have to fight heart disease, but they are not without their side effects. Thankfully the side effects of taking statins are few and, for the most part, mild. The two most common side effects that people experience are elevated liver enzymes and muscle cramps. In nearly all cases these side effects go away with cessation of the drug, and often times patients can find a statin at a dose that gives them significant benefit without any of these negative effects. As with every other drug ever marked in this country, the long, legally mandated list of potential adverse events of taking statins is lengthy (any negative event that occurs during the course of a clinical trial must be reported, even if it is completely unrelated to the drug being tested), but clinical trials have shown these events to occur with similar frequencies in the placebo groups (meaning that the true risk of serious adverse events while on statins is no different than the risk of serious adverse events when taking a sugar pill).
With all that being said, is there anything to all of this recent statin fear mongering? Below are the main issues that have been raised, and a brief scientific rebuttal to each.
1. Too many people suffer debilitating side effects from statin use.
As it turns out, statins are among some of the best tolerated drugs on the market. Side effects are minimal and, as stated above, serious adverse events occur at similar rates in both the statin and placebo groups in all clinical trials. So where did this “nearly 18% of patients experience side effects on statins” come from? As it turns out, it comes from a single recent study that had no placebo control group and that did a poor job of surveying patients for adverse events. In fact, each and every other study that has ever looked at statins has found that only 5-10% of patients experience any side effects while on the drugs, rates nearly identical to those experienced by subjects receiving placebo.
2. Cholesterol and fat are not the culprits in heart disease, so statins are useless drugs.
This is a sad piece of misinformation that unfortunately makes the rounds every once in a while. All experts agree that circulating cholesterol levels in the blood are directly linked to the development of atherosclerotic disease and heart attacks. The LDL particle (the little bubble of protein, fat, and cholesterol that is the major source of circulating cholesterol in the body) causes serious problems when it ends up in the walls of the blood vessels. Once in the blood vessel walls, it causes serious inflammation that results in the buildup of plaques and the formation of clots, both of which can completely block arteries over time and rob the heart of its necessary blood supply. Statins have been shown over and over again to both directly lower the amount of circulating LDL cholesterol and, in doing so, to reduce the risk of heart attacks.
While we know that circulating LDL cholesterol is directly linked to heart attacks and stroke, one area of active research involves the origin of LDL cholesterol, and this may be where the above piece of misinformation originates – we are still not entirely sure how big of a role the amount of cholesterol and fat in a persons diet plays when it comes to heart disease. As mentioned earlier, most of the circulating cholesterol in our bodies is produced by our own livers and only a minority is directly absorbed from the food we eat. Thus, the cholesterol and fat in food may not necessarily be the culprit in heart disease, but circulating cholesterol in our bodies, regardless of the source, is absolutely associated with increased risk of heart attack and death. This is not to say that we do not have good evidence that diets rich in animal fats are bad for you – multiple studies have repeatedly demonstrated that eating animal fats puts people at higher risk for cardiac events – but the exact relationship between the amount of animal fat and cholesterol consumed and the circulating cholesterol levels is still being investigated. Most experts agree, however, that diets low in animal fats are a huge part of a healthy and sustainable lifestyle.
3. We should not be prescribing statins to healthy people.
To be more specific, this argument should read “we should not prescribe statins to people with high cholesterol, but who have not yet proven that they have serious vascular disease.” It is certainly true that we live in a culture where there are pills for everything, from restless leg syndrome to smoking cessation, and it seems far easier to add more pills to a person’s pillbox than to ask them to make lifestyle modifications. And why would we prescribe a pill for heart disease to someone who doesn’t have heart disease, anyway – is there even any data to support that?
As it turns out, there is. Not very many studies have looked at using statins in “healthy” (i.e. people with elevated cholesterol but no known cardiovascular disease) individuals, but in the few studies that have looked, benefit has been seen in many cases. And this makes perfect sense. We know that the cycle of heart disease pathogenesis revolves around circulating cholesterol levels, so lowering these levels in people with statin therapy before they develop heart disease seems like a no brainer. In fact, we know that once atherosclerotic disease is established in a patient there is very little that can be done to reverse it. Initiating statin therapy only after a person develops cardiovascular disease (as some would suggest we do) is a little like hitting the breaks after you’ve driven the car off the cliff. – it would have been a lot more effective if you had hit the breaks before you got to the ledge.
Certainly more studies need to be done regarding the use of statins for primary prevention (i.e. prevention of cardiovascular disease before there is any evidence of it), but all the data we have gathered to date suggest that statins, for those who can tolerate them, should be started early.
Finally, to make a final point, look at this graph (from CDC, Health, 2009):
It’s shocking, isn’t it? We are doing an AMAZING job of reducing death cardiovascular disease (including heart disease and stoke) in this country, and this graph clearly drives that point home. Think of all the hundreds of millions of dollars invested in cancer research, and look at how little of a dent we have made in cancer deaths over the past few decades. Death from heart disease, on the other hand, has plummeted. While we cannot attribute all of this effect to statin use, it’s obvious that statins have truly changed the way we manage heart attacks, heart disease, and high cholesterol and have clearly saved hundreds of thousands of lives over the years. While there is certainly room for scientific debate over the use of any drug, particularly over a class of drugs so widely prescribed as statins, there is absolutely no room for data falsification, sloppy scientific writing, and fear mongering. I worry that this completely manufactured debate has already cost us many lives.
TeddyDr has no conflicts of interest or financial interest in statins or related drugs.