Spreading the Word on a Lifesaver: Statin Drugs
So maybe they really should put statin drugs in the water supply, as some heart doctors only half-jokingly suggest.
The put-it-in-the-water quip inevitably surfaces whenever heart specialists gather to talk pills. It echoes both their confidence in statins’ power to lower cholesterol and their frustration that millions miss out.
Statins are one of the true medical breakthroughs of recent times. They spectacularly reduce cholesterol, and they do it far better than even the most draconian diet and exercise programs. A 60-point drop in cholesterol is nothing special on statins.
Statins keep arteries from clogging and may even reverse the process. People on statins lower their risk of heart attacks by about one-third. And they live longer.
Furthermore, the drugs are easy to take, and side effects are rare.
About 8 million Americans now take them, but experts say 20 million, perhaps even 30 million, should be on statins.
Statin drugs “have had the greatest impact of anything I’ve seen over the past three decades,” says Dr. Antonio Gotto, a cardiologist and dean of the Cornell University medical school. “With wider application, they have the potential of making a tremendous dent in death and disability from coronary disease.”
Why are these life-saving medicines so underused?
Some patients are too pill-phobic to take them. And at $100 a month, price alone keeps many off the drug. However, prices are likely to fall in the next two to three years as the drugs lose patent protection and cheaper generics appear.
Some primary-care physicians are too out of touch to know much about the drugs, and others may not want the extra work involved in persuading patients to take statins, checking their cholesterol counts and adjusting the doses as necessary.
“Physicians tend to be a real show-me group that changes slowly,” says Dr. Calvin Weisberger, a Kaiser Permanente cardiologist in Los Angeles.
However, medical shortcomings have a way of healing themselves over time, and underuse of statins is likely to do the same. Experts estimate that statin prescriptions rose by almost one-third last year. And some doctors say the aversion to prescribing statins appears to be easing.
Five brands are available: Lipitor, Zocor, Pravachol, Lescol, Mevacor and Baycol. They are called statins because their generic names, such as lovastatin and atorvastatin, all end the same way. The first of them came on the market a decade ago, but much of the evidence of their worth has been amassed over the last five years.
The drugs inhibit a protein called 3-hydroxy-3-methylglutaryl-coenzyme A reductase, which is necessary for the liver to make cholesterol.
When statins first came into use, many doctors were leery that they might cause liver damage. But over time this has proved to be highly unusual, and the problem is usually reversible if patients quit the medicine or switch brands.
“Ten milligrams of statins is probably as safe as two aspirins,” says Dr. Richard Pasternak of Massachusetts General Hospital.
Doctors also were dubious at first because they had no proof that lowering cholesterol with statins actually saves lives. But this, too, has changed with a series of large landmark studies.
Committees of medical experts sometimes meet to help front-line doctors make sense of new medical evidence. The last time this happened for statin drugs was in 1993, when the federal government’s National Cholesterol Education Program drew up guidelines.
That was before the studies came out, but even then the committee recommended that people with heart disease get statins if their cholesterol levels are modestly elevated. It set the cutoff for cholesterol levels higher for those with no signs of heart disease.
This year the committee will meet to update the recommendations, and it almost certainly will lower the threshold for statin use. Dr. James Cleeman, head of the committee, estimates that under the 1993 standards, about 12 million Americans should be taking statins--50% more than are now. Some experts believe statins should be offered to at least twice as many people as the current guidelines suggest.
At some elite medical centers, doctors ignore the guidelines and put virtually all heart attack victims on statins, no matter what their cholesterol levels.
“We’re adopting the philosophy that your cholesterol is too high for you if you’ve had a cardiac event,” says Dr. Shelley Shapiro of USC.
There is some disagreement about giving statins to those who have no outward signs of heart trouble. But even here, evidence is building that outwardly healthy people with only mildly elevated cholesterol will live longer and better if they take statins.
The 1993 guidelines discourage statins for healthy people unless their levels of artery-clogging LDL cholesterol are at least 160. The biggest controversy among statin advocates is how low this number should fall. Some say 100 is a reasonable cutoff. Others push for even more aggressive cholesterol lowering.
“If you look at more primitive societies, it’s not uncommon to see adult males with LDLs less than 80,” says Dr. Steven Nissen of the Cleveland Clinic, a member of the lower-is-better camp. “We have simply set the standard too high. We’ve got to get LDL down to 60 to 80 and total cholesterol under 150. I think we’ll find if we do that we will literally stop this disease in its tracks.”
More statins studies are underway to see if Nissen is right.
