Worried about your STATIN?

The FDA has updated the labelled recommendations on statins, the class of drugs most commonly used to lower cholesterol. Like many things medical, there was "good news & bad news". On the plus side, doctors are no longer obligated to check routine blood tests to see if the liver is behaving properly on the statin. We know that there is the potential for a rare, severe liver complication, but it turns out that the routine screening of the liver enzyme levels are ineffective in detecting or preventing it. On the negative side, the FDA now warns against the possibility that statins may raise blood sugar levels, because in several large trials there has been a marked increase in diabetes in patients taking statins (compared to those receiving placebo.) Additionally, the FDA has noted that statins might cause some "minor and reversible cognitive side effects". What does that mean? Basically, there is a subset of people who notice significant short-term memory loss or difficulty concentrating when they take statins. The good news is that those mental changes seem to revert back to normal (or at least, pre-statin levels) once you stop the drug. AND that this side effect occurs in less than 1% of patients.

What does this mean? Should we pull statins from the market? Why take a drug to help your heart when it hurts your liver, muscles, and brain, and could cause diabetes? Well, obviously we feel that in most cases, the benefits far outweigh the risks for this class of medication. Statins have been shown to decrease the risk of DEATH from cardiovascular disease by up to 25% in certain populations- this is a good thing! But- here's the rub-statins are not a substitute for a healthy diet and daily exercise, and not everyone with elevated cholesterol needs to take them. My own father used to chase down his cholesterol pill with chocolate and butter (though in fairness, he exercised every day of his life until his Parkinson's disease robbed him of balance and flexibility in his early 80's). But I digress...

How should we decide if a patient needs a statin? Number one, everyone initially diagnosed with high cholesterol should have dietary counseling on a high fiber, low cholesterol diet and see if they can improve their numbers through the behavioral modification of diet and exercise. Two, there is a wonderfully useful tool called the Framingham risk scorethat will help predict your risk of a cardiovascular event in the next ten years. Plug in your cholesterol, blood pressure & smoking status, and see if adding a statin will significantly lower your risk.

BOTTOM LINE: As with EVERY medication you take, be sure you understand the true anticipated benefits as well as possible risks of statins, and stay tuned...what we rave about today (in medicine), we shake our heads about next year.

To Statin, or Not to Statin- That is the Question!

Okay, in this day and age of fixing everything with pills, we are often faced with whether or not to start a patient on a cholesterol lowering drug (a statin.) How can we decide if the benefits outweigh the risks? How much improvement can we expect from a medication?

Often, simply educating the patient about a high fiber diet will do the trick, especially if it is his or her triglycerides (the smallest breakdown product of fat) that are really high. Eating a diet with more than 25g of fiber per day will often lower lipid levels to our goal range. How do we do that? At the risk of beating a dead horse, it's MORE fruits and vegetables, plus some extra sources of high fiber such as beans, nuts, more berries, or high fiber cereals such as Fiber One or Bran Buds.

What is HIGH? Total cholesterol >200, triglycerides > 150, LDL (bad cholesterol) > 130 [or >100 if other heart risk factors such as diabetes, high blood pressure or smoking], or LOW HDL (the good cholesterol that takes away plaques) which is <40 in men and <50 in women. If you have more than one number above normal, it's time to consider either serious dietary modification or perhaps medications.

Luckily, we have a tool that can help us decide whether or not to start medications. The Framingham Risk Score looks at your lipid levels and calculates your risk of an adverse cardiac event in the next decade. You can plug in "improved" numbers (that you would get with a drug like Lipitor, Zocor, or Crestor) and see how much, if any , it lowers your risk.


BOTTOM LINE: If you are deciding whether or not to start (or continue) a statin medication, consult with your doctor and discuss your Framingham risk score!