PT Barnum Once Said ……
Before I get to the six percent rule I wish to voice the truth about the statin drugs many of us take to lower our bad cholesterol – the Low Density Lipoprotein ( LDL) component. They are saving lives, they are preventing heart attacks and strokes, and they should not be stopped unless there is a real good reason to.
There are the bottom dwelling types, the snake-oil salesmen, and the foolish out there who are attempting to scare many of us into stopping their lifesaving medication because they have potential side-effects, as every single drug, vitamin and food can have. And there are plenty of patients who should not be taking statins and who can have serious adverse effects from them. Recently the FDA did site a small but definite increase in diabetes in patients who take statins and yet, in spite of this, issued the following statements:
“Statins have been shown to significantly reduce the risk of heart attack and heart disease.”
“The new information should not scare people into stopping taking the drugs.”
"The value of statins in preventing heart disease has been clearly established."
"Their benefit is indisputable, but they need to be taken with care and knowledge of their side effects."
Since this latest warning, some patients have called me to let me know that they will no longer be taking their statin medication. Of these patients, many claim they listened to other “experts” on television and the radio and have found better alternatives to lowering their cholesterol. In my opinion, if you go out and purchase some crap talked up by some TV doc, some supposed wizard, or some clown hawking their natural and safer product, you are going to pay for it, with increased risk of stroke, heart attack, and death, not to mention the cost of the junk you just bought. I'm not a big fan of Big Pharma but at least they are regulated and do invent drugs that can be very helpful, like statins. The OTC stuff, sold on TV and the radio, by some snake-oil salesmen, is hardly regulated and meant to steal as much money from you as possible.
The Six Percent Rule:
Doubling the dose of your statin drug will not double it's effect. Doubling your dose of 20 mg of Zocor (simvastatin) will not lower your LDL from 140 to 70. The general, and quite accurate, rule is that doubling any dose of any statin will get you another 6% reduction in your LDL cholesterol.
If your are visiting your physician, and he raises your Zocor from 10mg to 20mg, because he wants your LDL reduced from 100 to 70 then, he ain't going to get you to that goal. More, likely, your LDL cholesterol will lower to (you do that math) around 94, or well short of your goal of below 70. In cases like this, it is often best to switch the statin to a more potent one, like Lipitor ( artorvastatin) or Crestor ( rosuvastatin). Lipitor is twice as potent as Zocor and is now a generic drug ; the retail price for it will be falling significantly this year. Crestor is twice as potent as Lipitor and is still a brand drug so be prepared to pay more for it.
In the patient I discussed, I suggested he change his medication to Lipitor 40 mg or Crestor 20 mg since that would lower his LDL ( you can do the math) by about 48 percent or down to below 70. Some physicians may suggest that you add a drug like Zetia or Niaspan, since they will also help you get your LDL numbers to goal, but these combinations don’t seem to protect you from stroke and heart attack as well as just using a statin by itself.
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Maurice Tougas
Poppi Iceland
Christine Bollerud
Dr. Vanessa Neumann
The Feral Conservative
Donna Carbone
Salon.com
Comments
But - I take the opposite stance on statins in a recent post (Naive, Uninformed, and Wholly Unrealistic). They were approved for prevention of a second MI and are now prescribed for elevated inflammatory indicators (CRP) and for first MI prevention. They have not been shown to make any difference to any meaningful outcomes when prescribed for these purposes, yet 24 million Americans take them. Something wrong there.
I suggest the readers to review trials like the Jupiter trial. This large trial clearly showed a very significant benefit to exactly those patients that the Nurse suggests they do not. Here is a link to it.
http://circoutcomes.ahajournals.org/content/2/3/279.full
http://circ.ahajournals.org/content/124/2/146.full.pdf+html?sid=6e6c5596-fb4b-42ac-9b63-242ca884c172
Again, I urge everyone to consult with their physican and NOT to make any changes in their treatment based on this blog or some of the responses.
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All Topics Treatment of lipids (including hypercholesterolemia) in primary preventionFind Patient Print Email Official reprint from UpToDate® www.uptodate.com
©2012 UpToDate® Print | Back
Treatment of lipids (including hypercholesterolemia) in primary prevention
Literature review current through: Feb 2012. | This topic last updated: Dec 9, 2011.
Statins — In contrast to the results seen with nonstatin hypolipidemic agents, a number of studies have demonstrated a benefit from lowering the serum cholesterol with statins in patients without clinical evidence of CHD:
•The West of Scotland Coronary Prevention Study (WOSCOPS) showed that cholesterol lowering with pravastatin reduced both the number of nonfatal myocardial infarctions and CHD mortality in middle-aged men with a serum LDL-C concentration above 155 mg/dL (4.0 mmol/L) (figure 2) [15]. There was a borderline significant 22 percent reduction in all-cause mortality. Long-term follow-up after completion of the trial found that these benefits were sustained and the reduction in mortality increased over five to ten years, despite equivalent post-trial use of statins between groups [16]. (See "Clinical trials of cholesterol lowering for primary prevention of coronary heart disease", section on 'West of Scotland Coronary Prevention Study'.)
•These observations were extended in the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS), which showed that lovastatin reduced the incidence of a first major coronary event (unstable angina pectoris, fatal and non-fatal myocardial infarction, and sudden cardiac death) in low-risk men and women without clinical evidence of cardiovascular disease (CVD) and LDL-C levels near the average for the general population (150 mg/dL [3.9 mmol/L], range 130 to 190 mg/dL [3.4 to 4.9 mmol/L]) [17]. These patients also had HDL-cholesterol levels that were below average for an age and sex matched cohort. For every 1000 men and women treated with lovastatin for five years, 19 major coronary events, 12 myocardial infarctions, and 17 coronary revascularizations could be prevented. No effect was seen on all-cause mortality.
•Similar results were seen in the ASCOT-LLA, which studied atorvastatin (10 mg) in men and women with relatively normal serum cholesterol levels but with hypertension and at least three additional cardiac risk factors, however there was a trend toward a reduction in all-cause mortality (hazard ratio 0.87, 95% CI 0.71-1.06) [18]. (See "Clinical trials of cholesterol lowering for primary prevention of coronary heart disease", section on 'ASCOT-LLA trial'.)
•The JUPITER trial of rosuvastatin 20 mg daily in healthy adult men and women with elevated C-reactive protein levels and LDL-C levels below 130 mg/dL (3.4 mmol/L) found a marked reduction in the primary endpoint of first major cardiovascular events and for all-cause mortality (hazard ratios 0.56 and 0.80, respectively). The absolute benefits for the primary endpoint was 0.59 events per 100 person-years and for all-cause mortality was 0.25 deaths per 100 person-years. This trial was stopped early for benefit which may exaggerate the true level of benefit, particularly for the primary endpoint [19]. (See "Clinical trials of cholesterol lowering for primary prevention of coronary heart disease", section on 'JUPITER trial'.)
Taken together, these trials suggest that statin therapy for primary prevention is effective over a wide range of baseline LDL-C levels and lipid profiles and carries a similar relative risk reduction to statin therapy in secondary prevention. The absolute magnitude of benefit, however, is typically lower than in secondary prevention, but greater than the benefit of treating mild hypertension. Additionally, a meta-analysis that reanalyzed existing trials of statins, but carefully limited the inclusion of patients to only involve those with no prior cardiovascular disease, found a reduction in mortality that was not statistically significant (risk ratio 0.91, 95% CI 0.83-1.01) [20]. (See "Clinical trials of cholesterol lowering for primary prevention of coronary heart disease", section on 'Meta-analysis'.)
Beware of people who spew out crap, whether they are selling you a drug or talking you out of taking one. I appreciate your kind words and I will try and be as objective as I can. Again, I am not a fan of big Pharma or pill popping instead of lifestyle changes but in the case of statins the data is quite clear ,for those patients that the guidelines suggest should take them.
1) Do you believe such a tiny reduction in risk can be measured reliably?
2) If you believe it can, do you believe drug companies and their CRO’s can be trusted to measure it reliably?
3) If you believe they can, do you believe such a tiny reduction in risk is worth bothering with?
4) If you believe it is, do you give your patients an idea of the magnitude of the reduction in risk involved? Do you tell them, “This stuff may prevent you from dying prematurely – but it probably won’t.”
Thanks.
And again, I ask you to review the trials I posted which , like you wrote , prevent deaths albeit only about a 0.25 per 100 patient years. It doesn't sound a lot until you realize there are a heck of a lot of patients taking it. Wish I could make Americans exercise , stop eating crap, and stop smoking. If I could I would tax every single food with high saturated fat, or high sugar content but even the Mayor of NYC failed to get a tax passed on soft drinks. From what I see , I suspect we will be unable to afford treating the masses of morbidly obese smokers.