Statin therapy has long been a topic of discussion for effective cholesterol management. It's no secret that elevated cholesterol levels can pose significant risks to our cardiovascular health. Consequently, healthcare providers often prescribe statins as a means to lower cholesterol and mitigate these risks. However, despite their effectiveness, statins often evoke hesitation and concern among individuals considering this form of treatment. Let's dive into why this hesitation exists, the positives of statin therapy, potential side effects, and non-statin options.
Understanding the Hesitation
It's important to acknowledge the apprehension many individuals have regarding statin therapy. Concerns often stem from the fear of side effects, the long-term commitment to this type of medication, skepticism about pharmaceutical interventions, and the potential to develop other conditions due to starting a medication. Or what lots of our clients come to us wanting… they just want the opportunity to learn what other options exist and if those options could be safe and effective for them. People also usually know someone personally who is or was on a statin, and they may have watched someone they care for not do well on a statin or end up having a cardiovascular event even while on the medication. Additionally, misinformation may contribute to confusion and doubt.
The Positives
It's essential to recognize the significant benefits that statins can offer, especially for those with severely elevated cholesterol levels. Statins work by inhibiting an enzyme involved in cholesterol production, thereby reducing the amount of cholesterol circulating in the bloodstream. Beyond the direct action of decreasing cholesterol in the blood, statins are also anti-inflammatory and decrease platelet aggregation. By doing so, statins help lower the risk of cardiovascular events such as heart attacks and strokes. In large research studies and for many of the people we love, statins act as life-saving medications.
The Potential Side Effects
Nevertheless, like any medication, statins come with potential side effects. These can range from mild to severe and may include muscle pain, liver abnormalities, digestive issues, and an increased risk of diabetes. It's important to note that while these side effects are possible, they do not occur in everyone. Furthermore, healthcare providers should closely monitor patients on statin therapy to mitigate any adverse effects and adjust treatment as necessary.
Lastly, a side effect, yet maybe positive of statins, is the controversy surrounding increased blood vessel calcification due to statin therapy after about 6 years of use. Calcification is the process in which blood vessels harden due to calcium deposits. Calcifications typically lines damaged vessel walls or occurs on top of cholesterol deposits. These calcified plaques are at risk of dislodging and clogging vessels, potentially causing strokes and heart attacks. However, research indicates that statin-induced vessel calcifications might actually be a sign of stabilizing the cholesterol plaques. So statins not only decrease the blood levels of cholesterol, thereby reducing the deposit of cholesterol into plaques, but the statins also change the plaque architecture to become more calcified and less likely to dislodge and cause other problems.
If you’re considering starting a statin under your physician’s recommendation, be sure to ask what their monitoring parameters are so that expectations are set, and you can decide if you are satisfied with how you will be assessed after starting the medication.
Exploring Options
For individuals hesitant about starting statin therapy, exploring alternative options may offer a viable path forward.
Know more about your particular risk:
Typically, people have been seeing their primary care/family physician for years for annual and routine bloodwork, and all of a sudden they are told that they’re being prescribed a statin because of high cholesterol. Seemingly out of nowhere, when cholesterol was never a concern previously. Then when they look back at previous bloodwork, they notice a steady creep of abnormally elevated cholesterol. Of course there are exceptions to this story, but unfortunately, this experience is common.
Once you or your doctor notice slightly elevated cholesterol, it’s time to have a conversation about it (and potentially start talking about the options we’ll discuss below). So often doctors will watch cholesterol begin to rise, but won’t start counseling their patients about trying to lower it until the levels become so abnormal that the treatment approach revolves around statins.
Another aspect of knowing your particular risk is knowing specifically what lab values–total cholesterol, LDL, HDL, or triglycerides–are abnormal and to what degree. This information may change what medication or supplement options would work best for you. Beyond a standard lipid panel, there are also some tests to assess the proteins associated with the abnormal lipid values (apoB, particle #, small dense LDL, etc.), markers of inflammation (high sensitivity or “cardio” CRP, homocysteine, AA:EPA, etc.), and markers of plaque activity (PLAC, MPO, etc.) which build the context of your specific cardiovascular risk profile. Imaging such as coronary calcium scores which show the extent of vessel calcification may also be beneficial. However, it might not be helpful to get a calcium score after already being on statins for more than 6 years because your score is more likely to be high due to the statins.
Lastly, if your personal or familial medical history includes additional metabolic or cardiovascular diseases, this could influence your personal risk and can narrow down your best options.
Medication options
There are low, moderate, and high-intensity statins, aptly named for their strength in lowering cholesterol (and causing side effects). There are also other medication types such as fibrates, bile acid sequestrants (resins), and cholesterol absorption inhibitors. Each of the cholesterol lowering medication types have specific indications.
Statins are best at reducing LDL numbers by inhibiting LDL production in the liver, and may have some benefit in lowering triglycerides and raising HDL. Fibrates are best at lowering triglycerides and may have some benefit in raising HDL. Bile acid sequesterants (resins) significantly lower LDL, but to a lesser degree than statins do. Cholesterol absorption inhibitors are best at preventing the absorption of dietary and intestinal cholesterol, thereby decreasing LDL numbers. Cholesterol absorption inhibitors are often combined with statins because one inhibits the absorption of dietary cholesterol and the other inhibits our livers’ production of cholesterol.
Non-statin options
Lifestyle modifications such as dietary changes, regular exercise, weight management, and natural supplements can all play a role in managing cholesterol levels. However, the effectiveness of these alternatives varies depending on individual risk factors, response to treatment, and overall health goals. For example, if your overall health goal is to live as long as possible, regardless of living with certain diseases or medications on board, statins have some of the best-supporting evidence to make that happen. If your overall health goal is to avoid medications as much as possible, and you are dedicated to changing your lifestyle and/or eating habits and taking a regimen of supplements, then it could be possible to manage elevated cholesterol without medications.
Dietary fiber helps get rid of excess circulating cholesterol. Our body concentrates cholesterol in the bile which makes it so good at helping us digest dietary fats. The gallbladder empties our bile into the intestines for fat digestion and once the bile has done its job, the intestines will reabsorb these bile salts (which are made up of cholesterol) and put them back into circulation. We can help keep that cholesterol in the feces for excretion in the bowel movement by increasing our dietary fiber. Hitting 25-35 grams of fiber daily can be helpful for lowering cholesterol.
Red yeast rice contains a naturally occurring statin. Therefore, the cholesterol-lowering effects by red yeast rice are by the same mechanism as prescription statins; however, in a much less powerful manner and because it is a supplement, there isn’t much regulation in terms of sourcing and production. The onus of quality lies on the supplement company and the consumer. Of note, there is a significant dangerous contaminant called "citrinin" that is toxic to the kidneys. Before purchasing a red yeast rice supplement, make sure the company has performed proper testing.
Niacin is a B vitamin that can be prescribed or supplemented in high doses for lipid-lowering effects, specifically by strongly lowering triglycerides, which in turn lowers circulating LDL. Niacin also helps to increase HDL levels. Side effects of niacin include intense flushing and itching of the skin and face (because niacin dilates blood vessels and increases blood flow). This side effect typically happens soon after taking a high dose of niacin and dissipates. Niacin can also cause liver enzymes to rise, so these should be closely monitored.
Other lipid-lowering herbs and supplements include: garlic, onion, olive leaf, artichoke, guggul resin, omega-3-fatty acids
It is crucial to consult with a healthcare provider to determine the most appropriate course of action tailored to your specific needs.
Summary
As naturopathic doctors, we understand the complexities surrounding cholesterol management and the decision to start statin therapy. It's essential to acknowledge the valid concerns and preferences of each individual.
While the decision to start statin therapy for elevated cholesterol may evoke hesitation, it's essential to weigh the benefits against potential risks while exploring alternative options. By working closely with your healthcare provider and making informed decisions, you can take proactive steps toward improving your cardiovascular health and overall well-being.
Written by Olivia Froehlich, N.D.
References
Ngamdu, K. S., Ghosalkar, D. S., Chung, H. E., Christensen, J. L., Lee, C., Butler, C. A., Ho, T., Chu, A., Heath, J. R., Baig, M., Wu, W. C., Choudhary, G., & Morrison, A. R. (2023). Long-term statin therapy is associated with severe coronary artery calcification. PloS one, 18(7), e0289111. https://doi.org/10.1371/journal.pone.0289111
Whalen, K. (2015) Lippincott Illustrated Reviews Pharmacology. 6th Edition, Wolters Kluwer, Alphen aan den Rijn, 311-324.