Lipitor, a cholesterol-lowering statin, remains the number one best selling drug bringing in $7.2 billion for 2012 even though it has been replaced by Vicodin as the most commonly prescribed drug. Another statin medication, generic Zocor (simvastatin), takes the number two spot for the most prescribed drug in 2012 with 94.1 million prescriptions due to its lower cost than Lipitor. With the increasing number of patients being prescribed expensive statins that require additional patient monitoring with an extensive side effect profile (muscle pain, liver damage, digestive problems, rash) and numerous drug interactions, one wonders why so many Americans are being prescribed statins and is it always medically necessary?
High cholesterol is a major risk factor in the development of artherosclerosis, the hardening and narrowing of arteries. The arteries work to pump blood all throughout the body from the heart. High cholesterol, high blood pressure, and smoking can all damage the endothelium (lining of arterial wall) allowing LDL “bad” cholesterol to enter through the wall and form a plaque. Plaques decrease blood flow through the arteries, and can cause chest pain (angina). A ruptured plaque can cause a blood clot resulting in a heart attack, stroke, or peripheral vascular disease – collectively known as “cardiovascular disease” (the number one cause of death in America).
Statins work by inhibiting an enzyme, HMG-CoA reductase, in the liver that is responsible for the production of cholesterol. Statins can lower LDL (“bad”) cholesterol by more than 30%, and physicians must consider the patient’s baseline lipid panel and other risk factors for developing cardiovascular disease when deciding on how to treat hyperlipidemia, an excess of lipids found in the blood usually caused by a lipoprotein metabolism disorder from lipoprotein overproduction. Physicians may prescribe lifestyle changes over statin drug therapy depending on the goal LDL reduction – triglycerides are only targeted first in drug therapy when in the “very high” category or still “high” after LDL goal is reached (see table below). In order for patients to understand how to take control of their own therapy, one must understand the difference between good and bad cholesterol and what numbers to be looking for during health screenings.
Cholesterol tests are usually repeated once every five years for prevention. The lipid panel is more accurate when the patient is fasting for 9 to 12 hours beforehand.
- HDL (high-density lipoprotein), also known as the “good” cholesterol act as “scavengers” for excess LDL cholesterol in the body by picking LDL up and breaking it down in the liver. Elevated HDL levels are a negative risk factor for cardiovascular disease.
- Ways to increase HDL levels: aerobic exercise; smoking cessation; elimination of trans fats from the diet, increasing the intake of fruit, vegetables, and monounsaturated “healthy” fats; and only a moderate consumption of alcohol (maximum of 2 drinks per day for men and 1 for women).
- Falsely elevated HDL level results from birth control pills and alcohol; drugs that decrease HDL levels: beta blockers and anabolic steroids.
- LDL (low-density lipoprotein), also known as the “bad” cholesterol for contributing to plaque formation in the arteries. The higher the LDL level, the higher the risk of developing cardiovascular disease.
- Triglycerides are a chemical form of fat found in the blood where a higher level is associated with an increased risk of cardiovascular disease. They can be pretty “ugly” in patients with diabetes that have a characteristically higher triglyceride level with usually only a marginally elevated LDL level.
If cholesterol is minimally elevated, diet and exercise changes may be advised before starting drug therapy when the benefits of the medication do not outweigh the risks. Preventing high cholesterol through lifestyle changes and regular cholesterol testing along with knowing your family history for cardiovascular disease should be a national concern to decrease the costs of medical care and more importantly, decrease patient morbidity and mortality.
Sources:
- Talbert RL. Hyperlipidemia. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM (eds) Pharmacotherapy: A pathophysiologic approach. 7th edition, 2008; 385-407.
- Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001; 285: 2486-97.
