October 2016 - NON-MEDICATED LIFE
Can You Reduce Reliance on Statins?
By Paul E. Lemanski, MD, MS, FACP
Editor’s Note: This is the 73rd in a series on optimal diet and lifestyle to help prevent and treat disease. Any planned change in diet, exercise or treatment should be discussed with and approved by your personal physician before implementation. The help of a registered dietitian in the implementation of dietary changes is strongly recommended.
Medicines are a mainstay of American life and the healthcare system not only because they are perceived to work by the individuals taking them, but also because their benefit may be shown by the objective assessment of scientific study. Clinical research trials have shown that some of the medicines of Western science may reduce the risk of heart attacks, strokes and cardiovascular death, while others may reduce certain types of cancer.
In the first 72 installments of the Non-Medicated Life, informed diet and lifestyle have been shown to accomplish naturally for the majority of individuals, many, if not most of the benefits of medications in the prevention and treatment of chronic medical conditions. When implemented by an individual, informed diet and lifestyle as a medical intervention may accomplish such benefits at lower risk for side effects, and may reduce the number and amount of medications, and may allow actual discontinuation of medication. This is true in many – but not all – situations for the class of cholesterol lowering drugs called statins.
Statin drugs such as atorvastatin (Lipitor), rosuvastatin (Crestor), simvastatin (Zocor), lovastatin (Mevacor), pravastatin (Pravachol), pitavastatin (Livalo), and fluvastatin (Leschol) markedly reduce cholesterol and may reduce LDL (the bad cholesterol) by 60%. More importantly in randomized, prospective clinical trials – the gold standard for research – involving collectively over 100,000 patients, statins also reduce the risk for heart attack, stroke and cardiovascular death. It is because of this proven reduction in events and deaths that physicians turn first to statins when choosing a cholesterol lowering medication to add to a prudent diet.
Statins, however, also may have side effects that limit the number of individuals who may benefit. For example, up to 10% of individuals on statins may experience muscle aches and muscle weakness that may result in discontinuation of the drug – so called statin intolerance. Many times statin intolerance is dose dependent. An individual may not be able to tolerate 40 mg of a statin drug, but may feel fine on 10 or 20 mg. Thus, reducing the dose of statin may allow the drug to be tolerated. Reducing the dose by 50% will result on average in only a 6% increase in LDL cholesterol.
This property of statins may be used with statin intolerant high-risk individuals to allow them to remain on drug. High-risk individuals are those already having had an event including a heart attack, bypass surgery, stent or stroke. A history of such an event places them at high risk for another event. For these high-risk, intolerant individuals the ability to take statin even at reduced dose achieves some benefit, even if the benefit is less. It is important to note that any decision to reduce the dose of medication should be made only after a complete discussion of risk and benefit with your primary care physician or cardiologist.
High-risk individuals may also include those without history of an event. Such individuals include those with diabetes. They may also include those with cholesterol plaque identified on imaging of arteries by stress test, cardiac catheterization, CT scan of the heart, or carotid artery ultrasound. In high-risk individuals most physicians will attempt to reduce the LDL cholesterol to the range of 50-70 mg/dl. High-risk individuals who cannot achieve this target on a tolerated dose of statin, may have non-statin cholesterol lowering medications added to their regiment. Unfortunately, many times even the use of multiple drugs still cannot lower their LDL cholesterol sufficiently.
For high-risk individuals who cannot achieve LDL target of 50-70, informed diet and lifestyle may offer a potent adjunct to medication. For example, a diet that restricts saturated fat to <15 grams/day and limits dietary cholesterol to under 200 mg/day may lower LDL cholesterol in some individuals by as much as 15-20%. One study showed that reducing saturated fat to about 15 grams/day may allow a 50% reduction in statin dose and get approximately the same LDL reduction – important for those who cannot take higher doses of medication.
For those willing to try a low fat vegan diet, such as the Ornish diet, reductions in LDL cholesterol up to 37% are possible. This is equivalent to the reductions seen with some statins. In high-risk individuals such a diet should be used as an adjunct rather than a replacement.
While exercise and weight loss generally have only a modest effect on lowering LDL cholesterol, both may alter the way LDL is carried in the blood. LDL is carried in the blood as spherical particles which range in size, small to large. Both weight loss and exercise increase the size of LDL particles, while decreasing their number. Such an effect may make it harder for LDL in the blood to gain access to the artery wall to form a cholesterol plaque.
Increasing consumption of soluble fiber to approximately five to ten grams per day may lower LDL cholesterol by 5%. This may be accomplished by increasing consumption of oats (3/4-cup dry = 3 grams of soluble fiber), beans and legumes (one-cup = 4.8 grams), Brussels sprouts (1/2-cup = 2 grams), ground flax seeds (one-tablespoon = 1.1 grams), and fruits containing pectin such as an apple (one apple = 1.7 grams). Soluble fiber is also contained in psyllium husks (Metamucil), with 2.4 grams per teaspoon. The use of plant stanols contained in certain margarines such as Benecol, and Take Control may also lower LDL cholesterol by up to 14%.
For high-risk individuals still unable to achieve LDL target of 50-70, a new class of cholesterol lowering drugs called PCSK9 inhibitors may be added to statin and achieve dramatic lowering of LDL cholesterol. While PCSK9 inhibitors dramatically lower LDL cholesterol, there is only preliminary evidence for event reduction. The drug cost is approximately $15,000 per year, limiting its use. Although long-term safety is still being assessed, the drug should be considered in high-risk individuals who cannot achieve LDL target in any other way.
Lower-risk individuals, however, may also benefit from informed diet and lifestyle, and may be able to reduce the dose – or even avoid the use of a statin. For example, those with higher cholesterol, who have not had a cardiovascular event or had cholesterol plaque identified on an imaging study, may consider a trial of diet and lifestyle before resorting to drug treatment. This requires assessing global cardiovascular risk and then determining a reasonable target for LDL cholesterol. Such a determination may be complex and requires the help of your primary care physician or cardiologist. Three months of a specific non-medicated approach will generally determine if this target can be reached. Those already at LDL target on a statin may institute diet and lifestyle for three months, and then – with the guidance of their physician – determine if the drug may be reduced in dose or stopped.
The only exceptions to first using diet and lifestyle would be in those low-risk individuals who had a family history of heart disease first manifested in a father or brother below the age of 55, or a mother or sister before age 65, or those with an LDL cholesterol >190. Such individuals may have unrecognized risk and should consult their primary care physician or cardiologist before settling on a non-medicated approach.
In summary, informed diet and lifestyle may reduce reliance on statin drugs – either by allowing a reduction in dose or possible discontinuation. High-risk individuals should, if possible, remain on statin to achieve an LDL target of 50-70. For those at lower-risk, the decision to reduce or discontinue medication depends on an individual’s LDL target – determined by your primary care physician or cardiologist – as well as the individual’s desire and ability to achieve that target.
Paul E. Lemanski, MD, MS, FACP (firstname.lastname@example.org) is a board certified internist at the Center for Preventive Medicine, CapitalCare Medical Group in Albany. He is medical director of the Department of Community Medicine and Population Health at CapitalCare Medical Group. Paul has a master’s degree in human nutrition. He is an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.