Under 25 years ago, 58,000 Britons took statins - now it's 7 million. With so many people having a vested interest in them, it's hardly surprising the media is always looking for miracle or scare stories to make us sit up.
Back at the start of the 21st century, I had a medical rap over the knuckles. Apparently, according to my pharmacy team, I was too free with my prescribing of a group of drugs with 'limited or no proven clinical value'. The drugs were statins, and the only people I was giving them to were patient who'd already had a heart attack. I had a meeting with my prescribing team, and explained the evidence as I saw it. I was particularly interested in heart disease, and had taken a keen interest in new research studies. In my mind, they showed clear evidence that statins, in the right people, would save lives.
Just a couple of years later, a study called the Heart Protection Study (1) came out. It showed that if you'd had a heart attack or stroke, taking a daily statin tablet a day could cut your chance of another heart attack by nearly one in five, and your chance of dying by 12%. Not long afterwards, other studies showed that many people with type 2 diabetes could cut their risk of heart attack or stroke by well over a third by taking a regular statin.
How things change. Today, I could be successfully sued for medical negligence if I didn't offer every heart attack or stroke patient a statin. Apart from younger women (statins shouldn't be used in pregnancy) almost all my patients with type 2 diabetes take statins. New guidelines recommend that if you have type 1 diabetes and are over 40, were diagnosed more than 10 years ago or have evidence of kidney damage, you too should be taking statins. And lots of other people take them too.
Anyone could have a heart attack - it's just a question of how big your risk is. Your doctor or nurse looks at all sorts of factors, including your age, gender, family history, whether you smoke, your blood pressure and cholesterol. All these add up to a 10-year risk of heart attack or stroke. If this risk is higher than 10%, you'll be offered long term treatment with a daily statin tablet. The level used to be 20%, and I certainly advocate statins to people with this level of risk. However, I'd much prefer it if people relied on side-effect free healthy living rather than tablets. For instance, if you're just teetering into the 'high risk' category and a statin is recommended, stopping smoking or making other changes to your lifestyle could mean you don't need statins after all!
The side effects of statins
Most people don't get side effects with statins - but, like every effective medicine, side effects do happen to some people. Estimates on how many people suffer vary wildly - largely because of the placebo (or in this case, the 'nocebo' effect - people who are told they might suffer a side effect are much more likely to complain of it).
For instance, in the landmark Heart Protection Study (1), participants were asked about muscle pain every time they were reviewed, and about 6% taking statins complained of muscle pain at any one visit. However, exactly the same number of people in the placebo group (who weren't taking any active medication but didn't know that) also complained of muscle pain. A later statin study showed a lower level of muscle ache, but again the same number of people in the statin and placebo group complained of it (2). Other studies have seen levels of 10-20%, but there were no comparable figures for patients taking placebo and no evidence that the statin was the cause (3). I also read with interestingly a recent study involving patients who had shown side effects to two statins before, who were either given a statin or another lipid lowering drug, including one of the new group of medicines called the PCSK9s. In each group, 20% had side effects and 80% had none (4).
In the short term, the most common side effects include abdominal pain, diarrhoea, feeling sick, headaches and rash. Most of these are mild and settle within weeks. Most people who get muscle aches are mildly affected - very rarely, these can be a sign of a serious problem, so if yours are severe, do see your doctor.
It's important not to stop your statin if you have minor side effects. The media tells stories of the very rare people who get very severe side effects, including muscle pains and memory problems. But they often don't put these side effects into perspective - the side effects for many people from NOT taking statins are heart attack and stroke. And while a few people report memory problems on statins, taking them may cut your risk of some forms of dementia.
Even if you are taking a statin, lifestyle changes can greatly improve your chance of avoiding a heart attack. The benefits of keeping your weight down; avoiding smoking; and taking regular exercise (aim toward half an hour of the sort of exercise that makes you mildly out of breath, on five days a week) all add up.
Diet can also make a big difference. A Mediterranean diet - lots of veg and fruit, more fish and olive or rapeseed oil, less red meat and full-fat dairy food - is ideal. While there has been debate about how bad saturated fat is, the balance of evidence suggests that switching to plant-based spreads and leaner meat will benefit your heart. Cutting down on salt can bring blood pressure down, making it less likely that you'll need a statin. Foods containing plant sterols or stanols can cut 'bad' cholesterol by up to 10%. Of course you can't change your gender or (more's the pity!) your age. But you can certainly change your lifestyle!
With thanks to 'My Weekly' magazine where this article was originally published.
1) MRC/BHF Heart Protection Study Collaboration Group. Effects of simvastatin 40mg daily on muscle and liver adverse effects in a 5-year randomized placebo-controlled trial in 20,536 high-risk people. BMC Clin Pharmacol 2009;9:6. http://dx.doi.org/10.1186/1472-6904-9-6
2) Hsia J, MacFadyen JG, Monyak J, Ridker PM. Cardiovascular event reduction and adverse events among subjects attaining low-density lipoprotein cholesterol <50mg/dl with rosuvastatin. The Jupiter Trial (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin). J Am Coll Cardiol 2011;57:1666-75.http://dx.doi.org/10.1016/j.jacc.2010.09.082
3) Sathasivam S. Statin induced myotoxicity. Eur J Intern Med 2012;23:317-24.http://dx.doi.org/10.1016/j.ejim.2012.01.004
4) Moriarty PM, Thompson PD, Cannon CP et al. ODYSSEY ALTERNATIVE: efficacy and safety of the proprotein convertase subtillisin/kexin type 9 monoclonal antibody, alircumab, versus ezetimibe, in patients with statin intolerance as defined by a placebo run-in and statin challenge arm [ClinicalTrials.gov Identifier:NCT017095131]. Presented at: American Heart Association Scientific Sessions: Late-Breaking Clinical Trials: Anti-Lipid Therapy and Prevention of CAD: Chicago, IL; 17 November 2014. Available from:http://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/@scon/documents/downloadable/ucm_469684.pdf
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