As a result, physicians have been eagerly encouraged to prescribe statins as a first line of defense and treatment. You've definitely seen commercials for Lipitor, Crestor, Zocor, etc. These are all marketable statins flooding medicine cabinets across America. A study by JAMA Cardiology reported that in 2013, over 39.2 million US adults over the age of 40 were regularly using statins (221 million prescriptions!). This is a 79.8% increase in prescription of statins from 2002-2003 when 21.8 million users reported using statins.
However, some controversy has come to light around statins and their efficacy. Studies have shown, and the Mayo Clinic has confirmed, that taking statins without lifestyle and diet change, has minimal long term benefit to patients. (Watch: Statin Misinformation Mayo Clinic Radio: https://www.youtube.com/watch?v=C_qQ7-Rkbak)
A randomized trial of 74 patients with hypercholesterolemia compared the use of statin therapy and an alternative treatment of lifestyle change and the ingestion of red yeast rice. This study found that the alternative treatment group saw significant reduction in LDL levels (- 42.4% p< 0.001) as well as in the statin group ( -39.6% p<0.001). The red yeast rice group also saw greater significant reductions in triglycerides and weight in comparison with the statin group.
If alternative treatments and preventative options that are HIGHLY suggestive of success are available, why aren't more physicians pushing lifestyle and diet as aggressively as statins? Is it because "big pharma" has made medicine convenient and easy? Is it because we know behavior change is more difficult than taking a pill? Is it because statin competitors are being silenced by pharmaceutical companies? Is it because physicians take the path of least resistance regardless of the unique and individual needs of our patients?
You tell me.
But here are some fun statin side effects as outlined by the Mayo Clinic and mandatory warnings included in every statin label for you to mull on:
1. Muscle pain and damage severe enough to make daily activities difficult
2. Liver damage: statins increase liver inflammation enzymes
3. Increased blood sugar or type 2 diabetes
4. Neurological side effects (memory loss or confusion. These side effect reverses once you stop taking the medication)
My parents are both over the age of 60 and their primary care providers push statins on them very aggressively even when their LDL and HDL levels are within healthy ranges. My dad refused to take statins and was given the warning that: "you might have a heart attack, but it's your choice." Scared, my dad took me along with him to his subsequent doctor appointments and was repeatedly told because of his age and gender, it was imperative he start a statin regime regardless of his diet. Again, my dad refused and switched providers to a Korean physician who was interested and familiar with his diet and lifestyle. She was the first doctor to tell him to try including red yeast rice and exercise to maintain and protect his healthy cholesterol levels.
These interactions cause me to think about how frequently physicians are digesting the constantly changing literature on best practice and what effect this has on their patients? Are drugs always the answer or can we widen our lenses a bit more?
References:
Becker, D. J., Gordon, R. Y., Morris, P. B., Yorko, J., Gordon, Y. J., Li, M., & Iqbal, N. (2008, July). Simvastatin vs therapeutic lifestyle changes and supplements: randomized primary prevention trial. In Mayo Clinic Proceedings (Vol. 83, No. 7, pp. 758-764). Elsevier.
Fuentes, A. V., Pineda, M. D., & Venkata, K. C. N. (2018). Comprehension of Top 200 Prescribed Drugs in the US as a Resource for Pharmacy Teaching, Training and Practice. Pharmacy, 6(2), 43.
Salami, J. A., Warraich, H., Valero-Elizondo, J., Spatz, E. S., Desai, N. R., Rana, J. S., ... & Blumenthal, R. S. (2017). National trends in statin use and expenditures in the US adult population from 2002 to 2013: insights from the Medical Expenditure Panel Survey. Jama cardiology, 2(1), 56-65.
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I can not believe that the doctor tried to scare your father like that with the heart attack statement, that seems so unethical! I know that the provider I worked with in a primary care clinic was very in favor of statin therapy and saw great results in LDL reduction similar to those mentioned from the study you linked, but we also did have some patients complain of the muscle pain described as one of the potential adverse side effects. It's very interesting to see the path that the view of statins has taken. They were once widely claimed to be incredibly dangerous and ineffective, then many seemed to view them as a miracle drug, and now it appears researchers are pulling back to a more realistic view which includes the potential negatives of statin therapy.
ReplyDeleteI think that this issue with regards to your father speaks to a larger issue as a whole. My mom was given notice of a heart condition as of recent and they are PUSHING the medication. I know that medication has its place and modern medication has changed so many things for the better but I feel like sometimes medication is pushed when there are better ways to prevent and heal ailments. I am going to do some more research on the medication they are prescribing my mom as you are doing with your dad but I am going to guess that regular exercise will actually have even better results as my mom is overweight.
ReplyDeleteI just had a severe déjà vu reading this post. I cannot count how many times I sat through similar statin conversations while working as a scribe. Warning, I’m going to play a mild role of devil’s advocate here. First of all, the way that doctor scared your dad was definitely uncalled for and unprofessional. I wouldn’t blame a patient for being weary about starting a medication if I presented it that way. However, statins are one of the medications that have been most studied and consistently shown to have a significant clinical benefit in patients with cardiovascular disease. I have provided a few studies (believe me there are a ton) that I found that show how statins significantly reduce the risk of having a recurrent myocardial infarction. In patients with all the risk factors, I mean, diabetes, hyperlipidemia, hypertension, family history of cardiovascular disease, known cardiovascular disease and especially multi-vessel coronary disease, statins are one of the best medications that these patients can be on. I will say, when providers (at least the ones I worked with) prescribe statins, they take into consideration all these risk factors because they are very aware of the side effects of medications. However, because evidence pointing toward its benefit in these patients is so strong, it outweighs the risk of side effects. I 100% agree with you, physicians should use a multi-lens approach and emphasize the importance of diet and exercise as well because these too have a significant power to reduce cardiovascular disease on their own. In fact, some providers might recommend starting with lifestyle modification first, to see if any improvement in lipids can be achieved and THEN if not, they would prescribe a statin. Also, last note, and I’ll stop, there are exciting new drugs called PCSK-9 inhibitors that are showing to be even more effective in reducing LDL compared to statins without the side effects and may often be in your prescription pads in the future.
ReplyDeleteChinwong, S., Patumanond, J., Chinwong, D., Hall, J. J., & Phrommintikul, A. (2016). Reduction in total recurrent cardiovascular events in acute coronary syndrome patients with low-density lipoprotein cholesterol goal <70 mg/dL: a real-life cohort in a developing country. Therapeutics and Clinical Risk Management, 12, 353–360. https://doi.org/10.2147/TCRM.S96016
LaRosa, J. C., Deedwania, P. C., Shepherd, J., Wenger, N. K., Greten, H., DeMicco, D. A., & Breazna, A. (2010). Comparison of 80 versus 10 mg of Atorvastatin on Occurrence of Cardiovascular Events After the First Event (from the Treating to New Targets [TNT] Trial). The American Journal of Cardiology, 105(3), 283–287. https://doi.org/10.1016/j.amjcard.2009.09.025
Matthew T. Rondina, & Muhlestein, J. B. (2005). Early Initiation of Statin Therapy in Acute Coronary Syndromes: A Review of the Evidence. Journal of Interventional Cardiology, 18(1), 55–63. https://doi.org/10.1111/j.1540-8183.2005.04103.x
Mega, J. L., Stitziel, N. O., Smith, J. G., Chasman, D. I., Caulfield, M. J., Devlin, J. J., … Sabatine, M. S. (2015). Genetic risk, coronary heart disease events, and the clinical benefit of statin therapy: an analysis of primary and secondary prevention trials. The Lancet, 385(9984), 2264–2271. https://doi.org/10.1016/S0140-6736(14)61730-X
Miller, M. (2018). Exploring the Role of PCSK9 Inhibitors in the Reduction of LDL-C in Patients with Dyslipidemia. Journal of Managed Care Medicine, 21(2), 27–39.
Sakamoto, T., Kojima, S., Ogawa, H., Shimomura, H., Kimura, K., Ogata, Y., … Kitagawa, A. (2006). Effects of Early Statin Treatment on Symptomatic Heart Failure and Ischemic Events After Acute Myocardial Infarction in Japanese. The American Journal of Cardiology, 97(8), 1165–1171. https://doi.org/10.1016/j.amjcard.2005.11.031