It’s hard to think of a medical concept (let alone any concept!) from the last quarter century that has achieved as much penetration into our culture than CHOLESTEROL.
Every patient I can think of, whether rich or poor, old or young, educated or not knows that “cholesterol is bad for you,” and that you should strive to “keep your cholesterol under control,” whatever that means.
Well, doctors are hammers, and we like to hit nails. Surgeons like to do operations. It turns out that the more they do, the better they get.
Primary care docs (such as internists, like me) run lab tests. When we see a value that falls outside of norms, we like to “do” something about it. Unfortunately, this has come to almost always mean writing a prescription.
The whole cholesterol hypothesis works very well with this paradigm, now that we have relatively safe and effective drugs with which to “treat” high cholesterol.
I put “treat” in quotes, since high cholesterol (except in rare cases where the cholesterol is sky high in genetic conditions) is not a disease, but a modifiable risk factor for vascular issues like heart attacks and strokes.
There is overwhelming evidence from the medical literature that people who control their cholesterol with statin drugs (simvastatin [Zocor], atorvastatin [Lipitor], rosuvasatin [Crestor], and others) have fewer vascular events (heart attacks, strokes).
This is because the drugs lower the liver’s manufacture of cholesterol in the body and alter the ratio of “good” cholesterol to “bad.” A lower level of circulating cholesterol helps reduce and stabilize the cholesterol-laden plaques that build up in our arteries, mostly due to our higher fat, highly processed American diets.
I still remember learning about this from a superb Grand Rounds lecture I attended more than a decade ago by Dr. Peter “I used to think I was incorruptible because I took money from EVERY drug company” Libby. His research demonstrates that statins not only reduce cholesterol in the blood and in arterial plaques, but even reduce the amount of overall inflammation in the blood vessel wall.
Some researchers have gone as far as suggesting we put statins in the water supply, since their benefits seem so clear and ubiquitous.
Yet as with all things that become a form of orthodoxy, there are contrarians. Start with those who’ve had side effects from the drugs: liver injury, muscle inflammation, and less specific aches and pains. Some question the long term effects of being on the medication; others question the incessant marketing of the drugs and the seemingly ever-expanding indications for prescribing them.
Should we prescribing statins for people without risk factors? Even when the cholesterol is not “high?”
It worries me that cholesterol has become the marker of virtue at the doctor’s office. It’s all due to oversimplification of the physiology and the major societal buy-in to these drugs.
For the more competitive patients, the lower the total cholesterol number, the higher the achievement. Never mind that what determines the number is largely genetics mixed with diet and exercise.
How big a role does diet play?
I admit, having prescribed statins for so long, I was skeptical that lifestyle alone could make a dramatic impact. I posted about what a dietary change did for me in the course of one month. I was quite surprised.
Of course, not everyone can make the lifestyle changes necessary to improve their health profiles. Behavioral change, like all change, is difficult to both initiate and sustain.
The statins give us an alternative to making this change. It’s just that we’re sliding quickly down the slippery slope to pushing them on everyone.
When you’re a hammer, you like to see nails. Even if you have to go out and find more of them.
I read this in a medical book a long time ago: You go to Midas, you get a muffler. If you’re having trouble with your knee, for example, but you really can’t or don’t want to have it surgically repaired right now, don’t go to an orthopod unless you tell him up front that you can’t have surgery now.
I’m a medical transcriptionist, paid on production, self employed, and at present, due to a very weird but not uncommon ADR to Levaquin, I am typing with a broken left radius & ulna and I can almost, after nearly three weeks, walk normally instead of shuffling along. Achilles tendonitis. I was so afraid of rupturing an Achilles that I called the ambulance and I’ll be damned if they didnt just hold onto my elbows and make me walk up the steps myself. The ER doctor told me basically that I was nuts, a drug seeker (Yes!! I admit it!!! I was hot for some Keflex!!!) and that I should continue the 750mg q.d. Levaquin. No thank you.
Anyway, Im on prednisone for a whole host of sequelae from an autoimmune gangrene, and I have to monitor my caffeine intake very carefully or I will be glued to the ceiling and fumbly-fingered. Im having a little trouble with that as it is. But sometimes you just have to have some espresso and that’s it. I love the McDonald’s iced coffee drinks, and so would you if your nearest Starbucks was 60 miles away.
now how the hell did this article get to statins? I have said for years that this would be the next class of drugs removed from the market. i dont eat fast food at all and don’t fry anything at all. No family history. And Im already on so many meds, I wouldnt be anxious to try them, unless I came up diabetic, and I’d just better not.
Im sorry if Im on the wrong thread. I wanted to comment on the one about caffeine and agree completely. It’s hard to transcribe much at 2 a.m. if you’re asleep on the keyboard, but those McDonald’s things, and when they say LARGE they mean it, can be addictive if you don’t get to enjoy much pure caffeine. I have to use half-caf coffee because of the prednisone.
no doubt, a fairly good-sized number of your statin Rx’s are written because a patient came in to see you and by God, they aren’t leaving without a prescription. I dont think you can ever educate people out of that.
Back to work now, glad I stumbled upon your blog even if I have posted comments in the wrong place. Its hard to type with a broken arm, which I believe I forgot to mention occurred when both Achilles slid out from under me and I fell on the bathroom floor, outstretched hand, of course. Still, with as few functioning brain cells as I have, its better than hitting the tub with my head.
You’re writing a book? Please keep me in mind if you need any help with the typing. I can’t see well enough to copy from handwritten notes, but I think that would be an interesting change.
It used to always irritate me that doctors were so quick to prescribe statins to people with elevated cholesterol levels. It was almost like it was the magic pill. I have since realized that very few people will follow the doctors orders to eat healthier and exercise. My dad’s cardiologist said that my dad was one of a few patients to actually follow his orders. My dad is now on statins due to genetic reasons. But he still walks his 3 miles a day and eats VERY healthy (he’s been doing this for 9 years). I think most cholesterol medications are over-prescribed because people are just plain lazy. If they only knew how much better they would feel by eating better. Plus, they would get the added benefit of losing a few pounds which would lower their risk for many health related problems.
I enjoy reading your blog. I found it after reading your lifestyle modification article.
Your Dad is definitely taking the right approach. Kudos to him–I hope he keeps it up, statin or not. Thanks for the comment!
-GH
My dad figured that as long as he had the statins, he could eat what he wanted… till his cardiologist revised his opinion rather sharply on the subject.
The BBC News – Health website just had an interesting article titled: ‘Unintended’ Statin Side-Effect Risks Uncovered”. Source: http://news.bbc.co.uk/2/hi/health/8695102.stm. It might give some pause to the idea of putting statins in the water supply when the side effects are added in to the risk profile. Here is what the BBC said:
For every 10,000 women treated with statins:
271 fewer cases of cardiovascular disease
8 fewer cases of oesophageal cancer
23 extra patients with acute kidney failure
73 extra patients with liver dysfunction
307 extra patients with cataracts
39 extra patients with muscle weakness
Figures were similar for men, except there would
be 110 extra cases of muscle weakness
Something to consider, and this analysis does not include the cost of prescribing these drugs.
Great blog, please keep it up.
I very much appreciate the link to the story and the comment. Many thanks!
-GH
However, most people in today’s ‘drug for symptoms’ culture stop at taking some thing that’s supposed to cure them. This can be only half the battle against cholesterol.
I attended a lecture by Dr. Nancy Olivieri last week, during which she discussed the role of pharmaceutical companies in clinical research and highlighted findings which suggest that Statins may have no effect on all cause mortality.
Of course you all know you can purchase the main statin….Red Yeast Rice extract…over the counter at any health food store. There are many clinical studies on this stuff. Believe it or not, a patient told me about this. Go figure…….
I have a GP who has been ‘threatening’ to put me on statins for almost a year. I’m disabled and not very active, though I am trying harder. I also should be eating better, but between having to depend on others to cook for me and not being able to afford some better foods, that doesn’t always happen either. I don’t know what is considered ‘too high’, my cholestrol being in the low 170s.
At my last visit, I asked for a suggestion from him while I was there about these annoying hot flashes (or ‘power surgers’ as some of us prefer!) and he told me to “go look around and pick up something at GNC”. Huh?? Well, I ended up with Black Cohosh Extract that helps, but worry that it may not mix with other medications I am on for pain and anxiety. Which brings me to what meant in the first place to comment on: while at GNC, I also found the Red Yeast Rice capsules, 600 mg. each. For some weird reason, maybe being me, I haven’t taken it after reading the label.
Now I read here that the main statin is this Red Yeast Rice. I’ve been eating a lot of oatmeal to try to lower my number, but does the Red Yeast Rice REALLY work? I feel like such a guinea pig sometimes, and other times medications make me ill, the doctor says to keep taking them. One I stopped is an Antidpressant (Effoxor XR) that I was told to keep taking even when I told the doctor how it even makes me vomit at times “Well take it with food!” Doesn’t matter.
In any case, I appreciate the VERY useful information, both in the articles and in the posts, and if someone could tell me if Red Yeast Rice is indeed safe or not when one is being ‘threatened’ already with statins, I’d surely appreciate that as well. (I apologize for the so long post.)
Correct me if I’m wrong, but doesn’t the Pfizer product label on Lipitor clearly state: “Lipitor has not been shown to prevent heart disease or heart attacks”?
As a heart attack survivor who was automatically put on statins post-op (along with a fistful of other cardiac meds), I can’t help notice that virtually all research touting the darling statin class of meds is funded by the very drug companies that manufacture the statins.
Consider, for example, the JUPITER trials on Crestor – funded not surprisingly by AstraZeneca, makers of Crestor. The study’s lead author Dr. Paul Ridker has also received grants and consulting fees from the same company. In fact, nine of the 14 authors of the JUPITER study have financial ties to AstraZeneca. And Ridker also happens to hold the legal patent on CRP blood-testing technology that stands to explode in sales now that his JUPITER study’s recommendations appear to be widely accepted by so many cardiologists worldwide. More on this at: “When Medical Research Is Funded To Favor The Drug – Not the Facts” at THE ETHICAL NAG: MARKETING ETHICS FOR THE EASILY SWAYED – http://ethicalnag.org/2010/07/19/jupiter-results-questioned/
Statins appear to be a truly miraculous class of drugs that will “cure what ails ya”. High LDL cholesterol numbers? Statins take care of those. Low HDL? Ditto. No lipid problems at all – but high CRP blood test results? HURRAY – your statins will address those, too! Low CRP numbers? Not to worry – statins will still cure you.
What about dandruff, acne, cognitive decline and halitosis? Surely there must be a statin out there that will fix those, too?