Half of the Spanish population has hypercholesterolemia (or cholesterol LDL, the bad, elevated), one of the main risk factors for cardiovascular disease, according to data from the Spanish Society of Cardiology (SEC). In addition, only 46.4% of them are aware of this problem. To lower it and keep it at bay, one of the most widely used drugs are statins, but its consumption – very high in Spain, grew by 442% between 2000 and 2012, according to the Spanish Agency for Medicines and Health Products – is not without controversy.
Scientific literature has been expressed both for and against these hypolipidators (a substance that decreases blood lipids). Like any other medicine, they do not get rid of a long list of side effects, such as myalgia, kidney, liver and stomach problems; erectile dysfunction, memory loss or diabetes. And even, as reported in Matter, an analysis in 2018 noted that there is an overprescription of these drugs in people over 40 years of age. The last argument with which this drug is attacked is that it does not work in cases where people are over 65 years of age and healthy. But what is the reality about the effectiveness of these pills?
Cases where they are indispensable
Doctors are clear that they work in some cases. For example, it says Rafael Ramos, a family doctor, a researcher in the Vascular Health Research Group at the Catalan Institute of Salut de Girona and a professor of Medical Sciences at the University of Girona, serves to "people who have already suffered or to who have a genetic disease that raises cholesterol and is at increased risk of cardiovascular disease."
"A diabetic, hypertensive or smoker are also considered to be high-risk patients, even when they don't have high cholesterol," says Alfonso Valle, head of the Cardiology Service at the Denia Hospital and a member of the Vascular Risk Section and Cardiac Rehabilitation of the SEC. Therefore, continues, "they need statins for LDL targets just as those who have suffered a heart attack". This expert points out that having a moderate risk is also a reason to prescribe them because, remember, there is a rule that all cardiologists know: "With 39 milligrams of cholesterol, cardiovascular problems decrease by 22% in 10 years." And to achieve this, he says, " there is no other drug that results better".
Its effectiveness in prevention is not provento be
Statin intake is related to a decrease in coenzyme Q10, an antioxidant nutrient that the body naturally produces and could help alleviate some of the side effects of the drug, research suggests that conclude that taking a supplement to this coenzyme could reduce the risk of muscle-related side effects.
However, doctors disagree: "There is no indication of co-administering it and it is not proven to have benefits for myalgia," Fierro clarifies. Valle, for his part, thinks it might have some effect on muscle pain, but recognizes that it doesn't always work,
The problem arises when consumed as a primary preventive treatment, it no longer protects everyone equally. "Because we don't know who they're going to protect, we have to find ways to decide who we're prescribing them to. To do this, the best way is to individualize patients and share the decision in an informed way", acknowledges Ramos.
Lack of a more fine-tuned calculation is what leaves the door open to the overmedicalization of statins in some patient profiles. Valles acknowledges that there may be "abuse in primary prevention, in patients without coronary or cerebrovascular events, who are given medication and have less on key factors such as physical exercise or diet," Says Valles. And it is not a problem of the doctor, the scientific literature also does not make clear its effectiveness as a preventive method: "There are studies that say it works effectively and others say that the balance between profit and risk is not clear. There are small studies that conclude that if the cardiovascular risk estimate exceeds 5% and has not had a previous event, there is evidence to recommend statin, but they are not large research," explains David Fierro, coordinator of the Lipids of the Spanish Society of Primary Care Physicians (SEMERGEN).
In the older population, where older age is accompanied by changes in metabolism and associated diseases, cardiovascular risk is triggered. Therefore, they are often given treatment to keep cholesterol levels low. But, "the formulas for estimating risk may not work in older people," acknowledges Ramos, who led a study, published in the British Medical Journal, on the questioned effect of statins on healthy older people: "We have not seen any differences between taking them and not taking them, except when used in a high-risk group such as people with diabetes, where there is benefit. And from the age of 85, even in diabetics, we see no benefit in starting to prescribe preventive statins." Therefore, this expert believes that the key is always to be guided by the risk that the patient has: "If this were done right, it is very likely that the consumption of statins in general would be reduced, and there would be changes that people who take them without need and those who don't take it despite needing it."
It's not a substitute for good lifestyle habits
And in cases where they work they cannot be taken as a free route to lead a poor quality of life. Just as eating fruit doesn't make up for being a smoker, statins don't give free rein to poor food and a sedentary life. Changing these habits when they are bad is the first thing specialists recommend: "Drugs are the last option," says Luis Cabañas, nutritionist and board member of the Official College of Dietitians and Nutritionists of the Comunitat Valenciana (CODiNuCoVa) and recalls the need to "address lifestyles".
There is no other drug that can be as effective as routine change, shares the family doctor Fierro. "However, lifestyle default rate is the highest of all non-compliance. If I were able to have my patients change their lifestyle, I'm sure my quota's pharmacological expense would be more than half. But administering statin means that the lifestyle has failed. Statin is a complementary measure to change lifestyle, but nutrition cannot be confronted with prescription," says Fierro.
There is currently no alternative to equalise the effectiveness
In recent years, statins have benefited from competitors: natural or nutraceutical supplements to reduce cholesterol in people at low risk. "The red yeast nutraceutical rice, with which the first statin was synthesized, is an alternative that the guides already collect, but when there is a clear indication of statin they cannot conflict", Fierro ruling. It can be prescribed in cases of primary prevention, indicates this expert, who points out that while they are endorsed by studies, their effectiveness is much lower than that of statins: "Instead of lowering cholesterol by 30%, they reduce it by 8%".
Science continues to look for other drugs and a recent study, published in the New England Journal of Medicine, targets bempedoic acid as it helps block an essential enzyme in the body capable of increasing blood cholesterol levels and enhance the effect of the same statins, as well as avoidside effects such as myalgias. But for now it's not an option for patients,
We recall that "there are no effective alternatives on the market for statins. They are in development and need more evidence. Some of these drugs have not come on the market after some studies. We need more research to talk about alternative treatments to statins. Despite side effects or inadequate risk-based administration, statins play their function," he concludes.