The pros and cons of using statins

The 4S study was followed a year later by the West of Scotland Coronary Prevention Study (WOSCOPS), which revealed significant benefits for people who had not yet had a heart attack or stroke. Statins also reduced the overall risk of death from coronary heart disease by 28 percent, and reduced the risk of death from other cardiovascular diseases by 25 percent among people with very high LDL cholesterol.

“A 20-year follow-up of that study showed that early intervention also provided benefits,” says Prof. Choudhury.

So why not give everyone a statin? “When we start statins, we need a clear idea of ​​what the goals are – whether we want to reduce the risk of a current heart attack or maintain cardiovascular health,” says Prof. Choudhury. “But your cholesterol levels should not be viewed in isolation. They should be interpreted in conjunction with an individual’s other risk factors and health attitudes, in a holistic sense.” The higher the risk of heart attack or stroke, the more beneficial statins become, he adds.

Most doctors now consult an algorithm called QRisk. A healthcare provider will measure your blood pressure, cholesterol, height, weight and waist circumference and ask questions about smoking, alcohol consumption and exercise. These are put into a computer and calculate your ‘QRisk’ score, which is your risk of having a cardiac ‘event’ in the next 10 years.

A low QRisk score of less than 10 percent means you have less than a one in 10 chance of having a stroke or heart attack in the next ten years, and a higher QRisk score of more than 20 percent means you have at least a chance of two in ten say an event will take place in the next ten years.

According to the NHS, statins are generally prescribed if someone has a risk of more than 10 (in the United States this is lower at 7.5 percent). “The threshold is somewhat arbitrary,” says Prof. Choudhury.

My most recent QRisk score, calculated in February 2024, was 9 percent: just below the NHS limit.

Are stains distributed too liberally?

But amid what seems like overwhelming evidence that statins can be lifesaving, there is growing skepticism. Critics argue that these pills may be distributed too liberally and that many people should not take them at all.

Others think statins may even be bad for us. In his 2014 book The great cholesterol deception Scottish GP Malcolm Kendrick argues that high cholesterol does not cause heart disease, that statins have far more side effects than admitted and that their proponents should ask more questions.

Prof. Gareth Morris-Stiff is a consultant liver surgeon at the Cleveland Clinic Lerner College of Medicine in Ohio and the global Chief Medical Officer of Equilibrium. “The data on statins is not perfect,” he explains. “These medications are not for everyone. As we know, all medications can cause side effects. The problem comes when you give them to everyone without discrimination, which is more the case in the US, but increasingly so in Britain. I don’t think the message is correct: ‘everyone should have a statin’.”

The possible side effects of statins

Common side effects of statins include muscle pain, weakness and stiffness. “They can also lead to transient liver dysfunction,” says Prof. Morris-Stiff. “Statins are known to increase certain liver enzymes. In the short term this may be insignificant, although we cannot be sure. But in the long term, patients taking statins can develop liver fibrosis, thought to be caused by inflammation. Statins do not prevent the development of fatty liver disease and may even promote it.” Conversely, some recent studies suggest that statins may have a protective effect on the liver.

Prof. Morris-Stiff believes there have not been enough studies to show the long-term effects of statins on the liver. “The relationship between cholesterol, statins and liver disease is not clear, and the waters are muddy,” he says.

He cites a former patient who had been taking statins for 26 years and underwent regular liver tests that upon further examination revealed serious liver abnormalities. “You can’t say with 100 percent that he didn’t have this problem before he got statins, but the link has to be ruled out,” he says. “All patients with metabolic syndrome (a cluster of conditions that increase the risk of heart disease, stroke or diabetes) should have baseline liver testing before starting statins.”

Prof. Morris-Stiff describes what he sees as “an obsession with fat and cholesterol.” “Statins have made Big Pharma billions,” he says. “There is now a philosophical discussion about cholesterol and statins, because in the late 1970s and 1980s we were told that ‘fat is bad’ for you. We were also told to convert fats to carbohydrates and eat three square meals. (Yet) there is an increase in obesity.”

According to Prof. Morris-Stiff, the focus on fats and cholesterol is misplaced and the real problem is sugar and a diet high in carbohydrates. “My big concern is insulin resistance and accelerated diabetes in ethnic groups such as those from the Indian subcontinent, because they cannot process carbohydrates as efficiently and are at increased risk of metabolic syndrome,” he notes.

Prof. Morris-Stiff would like to see more research detailing who benefits from statins and who is most at risk for side effects. “We need to identify a biomarker for response to statins,” he says. In the meantime, he would like people to consider alternatives.

A 2022 study in the journal Pharmacological research found that taking plant sterols (or extracts) can cause a modest reduction in LDL cholesterol. Prof. Morris-Stiff points to other articles in nutrition magazines that point to the usefulness of herbal remedies, including ginseng and curcumin, in lowering cholesterol.

“Herbs do not treat diseases, but they do provide balance,” explains Prof. Morris-Stiff. “We describe these as ‘phytomedicines’: we cannot say that they treat cholesterol.”

Are there natural alternatives to statins?

Can natural medicines really take the place of pharmaceuticals? “The first thing we have to say is that people have to be sensible,” says Prof. Morris-Stiff. “For example, if you have genetically high cholesterol, you should talk to your doctor. But before we automatically start medications with documented long- and short-term side effects, we need to address the underlying issues with diet and exercise, try to modify them, and exhaust these options first.”

Conventional physicians continue to dispute some of the most flowery claims against statins.

“Some people are skeptical of Big Pharma, perhaps because the use of these drugs is so widespread,” notes Prof. Choudhury. “But again, the response is to go to the hard data – there’s so much of it. You have to look at the quality of the evidence.”

Prof Choudhury accepts that some patients experience muscle pain as a result of taking statins, and that there is a low risk of a serious muscle inflammation called rhabdomyolysis. “But that’s 1.5 per 100,000 people treated,” he says. “There is some evidence that statins increase the risk of diabetes by a small amount (about one in 200 patients treated in one particular clinical trial), but the net effect was still very beneficial and mean glucose levels remained unchanged.

“There is no evidence that statins cause cancer, or that they cause dementia,” adds Prof. Choudhury.

How to weigh all the information about statins against each other

Amitava Banerjee is Professor of Clinical Data Science at University College London and Honorary Consultant Cardiologist at University College London Hospitals and Barts Health NHS Trusts. “It’s fine to ask questions, but we need a framework,” he says.

“When deciding whether information is worth taking seriously, I apply a very simple algorithm: have I received credible evidence? What expertise does the source have? How much experience do they have? Did they just watch a YouTube channel? Are they missing one or all of the above? Do they have a book to sell?

“People might say, ‘I like the natural treatment,’ but any systematic review has to be independent,” he notes. Prof Banerjee has “no problem” with lifestyle solutions or functional medicine. “It’s not an either/or,” he says. “You can take a statin and live a healthy life. The problem is that the critics present an either/or world, and this is not based on evidence.

“There is a misunderstanding in some quarters about the evidence,” he continues. “It is possible that some practitioners exaggerate the importance of lifestyle interventions, which may not work as well as we age. Diet or exercise may not be enough for some people.”

Prof Choudhury emphasizes the importance of a patient being “on board” when starting a statin. “The evidence shows that people are more likely to adhere to long-term preventive medicine if they are in favor of it,” he says. “It’s not my job to tell people what to do, or to bring a drug to market. The patient makes the decision. Maintaining trust is key to the doctor-patient relationship. These drugs are not a life sentence.

“I would advise a patient to get informed and go to a doctor he trusts and who will give him evidence-based advice on which he can base his decision.”

All of this still leaves me with that decision of my own.

I haven’t consulted a doctor since my borderline QRisk ‘nine’ early this year. But in the last few months I have lost almost a stone. So even though the ‘age’ part of the algorithm has gone up, chances are I’m still on the right side of the NHS equation. For now, I’m sticking with the lifestyle, diet and exercise option. As for the future? My mind remains open and I may still take statins one day.