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  • Alan Frischer, MD, MPH

Statins

One of the most popular and most controversial class of drugs on the market today are statins. Statins offer tremendous health benefits, but do come with a list of potential issues.


Cholesterol is a fatty substance, made in the liver. It serves an important function, but in excess it causes plaques that stick to the inside of blood vessels. This leads to atherosclerosis and increases the risk of cardiovascular disease, stroke, and a number of other conditions.


Statins block an enzyme that tells the liver to produce cholesterol. Statins also influence endothelial function, the inflammatory response, and coagulation. The first statin was discovered by a Japanese microbiologist in 1976. Later, Merck’s lovastatin became the first FDA approved statin. Since then, more statins have become available, and now some 25 million prescriptions are filled every year!


What are the benefits of statins?

  • First and foremost, they lower lipids. Cardiovascular disease currently causes one-third of all deaths globally, and increased LDL (“bad” cholesterol) levels are one of the major risk factors. If you follow my columns, you will know that I write this with reluctance, but statins are markedly better at lowering LDL than even diet, exercise, or weight loss.

  • Statin drugs also decrease inflammation and maintain normal blood vessel vasodilation, and as a result, improve the health of the endothelial wall. Endothelial cells line the interior of our blood vessels. When this lining starts to falter, it allows for atherosclerosis to occur. Other risk factors that contribute to this process include hypertension, smoking, and diabetes. (Statins not only benefit those with high cholesterol, but also improve endothelial health for those with normal cholesterol. This is why diabetics take statin drugs regardless of their cholesterol levels.)

  • The last step in atherosclerosis occurs when the endothelium is damaged and a blood clot is formed, impairing blood flow. Statins may slow or prevent this blood clot formation, and even promote clot destruction.


What are the downsides of statins?

  • The most common side effect is muscle pain, which occurs in fewer than 5% of those who take statins, and resolves when the medicine is stopped.

  • There is an increased risk of developing diabetes in patients taking statins. This is also rare, and the risk is highest in those with other diabetes risk factors, like obesity, impaired fasting glucose, or a family history.

  • Although the risk of ischemic stroke is reduced by statins, it’s possible that statins may increase the risk of hemorrhagic stroke. This risk is greater for patients with a history of stroke.

  • Statins may increase blood levels of liver enzymes; however, this won’t necessarily lead to serious liver injury. Approximately 1% of people taking statins experience this, and it usually resolves in time even if statins are continued.

  • Since 2012 the FDA added cognitive impairment side-effects to the drug label of all statins. However, large studies have found similar rates of cognitive impairment among patients not taking statins. Research is ongoing.


As always, talk to your doctor about the pros and cons of taking statins. I suggest that you discuss your cholesterol level, whether or not diet or lifestyle changes can lower your numbers enough, and whether your existing risk factors could make side effects a problem for you. I urge you to consider lifestyle changes, including cutting back on red meat, full fat dairy products, fried foods, and packaged goods that contain hydrogenated oils and trans fats. Eat vegetables, fruits, whole grains, nuts and fish. Quit smoking, vaping, or using any tobacco product. Exercise, maintain your weight, and limit alcohol. If you have had trouble with statins in the past, it’s possible that over-the-counter remedies and other classes of prescription medication can work for you.


I counsel my own patients that statins are highly effective and can reduce the risk of major cardiovascular events. The risk of side effects is significantly smaller than the benefits, and are almost always mild. Of course, given how common statin therapy is, we will continue to hear about those few patients who have problems with them.

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