Getting off statins is easy. Stop swallowing the pill. If you’re not in a potentially high-risk group (as described below) and your doc prescribed a statin to get your cholesterol down a bit, you won’t have a heart attack or a stroke that day or week or probably that decade.
There’s no “statin withdrawal” and you weren’t born with a statin deficiency.
In fact, many of you quitting statins will probably start feeling better in just a couple weeks. I admit “better” is rather vague, but perhaps you’re so used to having achy muscles, fatigue, and brain fog that you think these symptoms are normal.
Does my recommendation to stop taking your statin sound glib, a bit cavalier? After all, when you were handed the prescription you were told something like “You must take this every day or you’ll get a stroke or heart attack.” And now I come along suggesting that for most of you statins are simply not necessary…provided you’re willing to take charge of your health.
A new verb: deprescribing
The statin controversy is quite lively among physicians themselves. John Mandrola, MD, a cardiac electrophysiologist from Louisville, wrote a short blog post on the physician-only portion of Medscape expressing his doubts about statins. You can’t link to his piece without a password, but do have a look at Dr. Mandrola’s very good website and especially at this piece, “To Deprescribe…Adding a New Verb to the Language of Doctoring.”
Dr. Mandrola’s Medscape post received an astonishing 631 physician comments, most of which supported his position, namely that the latest guidelines from the American College of Cardiology (ACC) on statin prescribing were not only unrealistic, but potentially dangerous.
There are four guidelines regarding who should take statins. Many physicians in the US and most in Europe agree with the first two, partially with the third, and not at all with the fourth (my comments in italics):
- People 40 to 70 with Type 1 or 2 diabetes. This group has an increased risk for heart disease, including heart attack, and taking statins has been shown to reduce this risk. (However, diabetes is a potentially reversible condition with weight loss and exercise, and once the diabetes has been reversed it is possible to go off statins.)
- People with a history of a cardiovascular “event” such as heart attack, stroke, transient ischemic attack (TIA), angina, or peripheral artery disease (statins definitely reduce the chances for a second such event).
- People 21 or older with a very high level of bad cholesterol–LDL 190 mg/dl or higher. (Even though the high cholesterol may be genetic rather than lifestyle-induced, you needn’t capitulate entirely to your genes. Healthful eating, weight reduction, and exercise can bring down high cholesterol of any kind, including genetic. If, after several months of lifestyle changes, your cholesterol remains stuck in a danger zone, then taking a statin is reasonable, especially if along with genetic high cholesterol you also have a genetic premature early death risk.)
- People 40 to 75 with no cardiovascular disease, a (bad cholesterol) LDL of 70 mg/dl or higher, and who have a 7.5% or greater risk of having a heart attack or stroke within 10 years (the 7.5% or higher is predicated primarily on reversible lifestyle factors—see more below).
Note: the ACC does acknowledge that beyond age 75, there is no significant data showing any heart disease prevention benefit from statins.
It’s Number 4 that caused a great deal of eyebrow raising among doctors. The risk factors that would put a person in the 7.5% category include genetic susceptibility, yes, but also smoking, obesity (especially belly fat), inactivity, high blood pressure, and a significant family history of early heart disease. When these factors are combined with the newly established LDL of 70 mg/dL, it’s estimated that in the US alone the number of current statin users would increase from 12.8 million to 48 million.
If you’ve been following the news on bad cholesterol over the years, it used to be worrisome when LDL was higher than 100 mg/dL. According to the ACC guidelines, 36 million more people now need statins to hit that glorious 70 mg/dL. That means one adult in three would be taking statins, as many as one billion statin users worldwide, and total statin sales at $1 trillion a year.
But wait a minute. Except for the genetic susceptibility to early heart disease, every one of those factors that would place someone in the 7.5% risk group is reversible with lifestyle modification. And, most importantly, lifestyle changes will help even if you’re genetically predisposed to heart disease. Also, the newly available Corus-CAD test (which I discussed in a previous Health Tip) can confirm or refute your personal genetic susceptibility. If you’re concerned about your susceptibility to heart disease, I do suggest the Corus-CAD. It might be a good idea to get this test if you’re in that LDL group with 190 mg/dL or higher.
With all this in mind, read these aloud.
- Lifestyle beats statins every time. A healthy lifestyle is the foundation of cardiovascular health, period. There has never been a study undertaken to prove that statins are superior to lifestyle changes, and you can probably guess why: lifestyle would win hands down.
- Preventable heart attacks. A recent Swedish study proved that four out of five heart attacks in men were completely preventable. When 20,721 men agreed to stop smoking, eat healthfully, lose weight (belly fat, people), and reduce alcohol, after ten years there was an 86% reduction in the number of expected heart attacks for that number of men.
- False reassurance. Recent studies also show people who take statins eat more, move less, and gain weight, thus increasing their heart disease risks and cancelling any already dubious benefit they think they’re receiving. People who take statins are falsely reassured (in the well-chosen words of JAMA: Internal Medicine editor Rita Redberg, MD) that they’re getting some protection.
Statin side effects
Statins work by blocking an enzyme called HMG-CoA reductase, which controls cholesterol production in the liver. However, this enzyme is also responsible for your body’s production of coenzyme Q-10, a powerful antioxidant that prevents age-related macular degeneration, heart disease, and fatigue. The muscle pain caused by statins (the pharmaceutical industry reports this at 2%, primary care physicians at 30%) occurs as the statin lowers your CoQ10 levels.
As a side note, everyone (and I do mean everyone) taking statins should also be taking CoQ10 (100 mg UBQH daily).
Statin use has also been associated with memory impairment (25% of your body’s cholesterol is in your brain) and with the early onset of cataracts (27% increased risk among statin users).
One reason statins are a no-no in older adults is that a recent NIH study showed that after age 70, best memory function was observed in those with highest cholesterol levels.
Back to Dr Mandrola
Among the 631 physician comments that Dr. Mandrola received on his blog, several pointed out that doctors virtually had to prescribe statins because they couldn’t offer their patients nutritionists and exercise equipment (or, I would add, prescribe it with the expectation the patient would be reimbursed) and that many patients simply were so chronically noncompliant with health care advice that the doctor was lucky if she could get them to take the statin itself.
Dr Mandrola was sympathetic, but felt an attitude change among physicians was in order.
Sidebar: WholeHealth Chicago has three nutritionists and although most WHC patients work out regularly, I do maintain for my patients a rolodex of personal fitness trainers.
Physicians at the blog also asked about other cholesterol-lowering agents (such as prescription niacin, called Niaspan, and Zetia, which works by blocking cholesterol being absorbed from the digestive tract) and supplements (red yeast rice, plant sterols). Again, however, taking pills misses the point. All of these do lower cholesterol, though not as dramatically as statins, but none is superior to lifestyle modifications for overall heart disease prevention.
In the 15 years since WholeHealth Chicago opened, I’m aware of exactly two patients who died of a heart attack, and both were at high risk when they arrived. I attribute this really low number to the majority of our patients being highly motivated to live lives of wellness. They accomplish this via healthful eating (guided by our nutritionists if needed), weight reduction, and regular exercise. I can’t think of a single patient who’s still smoking.
Patients who resist the sort of DIY efforts we endorse seem to just drift away to pill-pushing medical practices where physicians are agreeable golden retrievers in comparison to our own WHC wellness wolverines.
Return to the four reasons for statins listed above.
- If you’re in groups 1 or 2 (you have Type 1 or 2 diabetes or you’ve had a previous cardiovascular event), stay on your statin. If you’re mildly diabetic, know it’s reversible and being statin-free is a possibility.
- If you’re in the third group (LDL over 190 mg/dL), meet with a nutritionist, start eating well and working out, and get further testing, especially the Corus CAD. You’ll probably be able to stop your statin in a few months.
- Members of the fourth group are likely taking statins unnecessarily. You may be thinking it’s helping when it’s really not. Stop your statin, review the discussion of lifestyle factors above, and get to work on yourself. If you simply cannot commit to significant lifestyle changes, then you might as well CYA and go back on the statin. Just don’t expect it to perform miracles.
David Edelberg, MD