Hypercholesterolemia, or high blood cholesterol, can be caused by many factors: genetic, diet, physical activity and other medical conditions. It is a well-documented fact that high levels of blood cholesterol increases your risk of cardiovascular diseases, such as heart attack, stroke and peripheral artery disease (PAD). You may read our article here for a detailed explanation of cholesterol. 

Image credit: https://www.everydayhealth.com/high-cholesterol/treatment/cholesterol-lowering-medications/

The National Health and Morbidity Survey (NHMS) 2019 found that 38.1% of Malaysians have high blood cholesterol levels, with 24.6% of them not knowing they actually have it! Fortunately, hypercholesterolemia is a relatively simple medical condition to treat -- doctors usually prescribe a group of medications known as the statins.

There are various cholesterol-lowering medications out there, but statins remain as the most prescribed one (96%). If you have been diagnosed with hypercholesterolemia or some forms of cardiovascular diseases, and modification of diet and physical activity did not improve your blood cholesterol level, it is likely that you are taking one of the statins.

Here are 5 facts about statins:

1. Not all statins are the same.

Statins are a group of medications that lower your blood cholesterol level. They all lower your blood cholesterol in the same way, but they are different in terms of pharmacokinetics. The most important aspect is the duration of each statin stays in your body. The doctors and pharmacists know this as the ‘elimination half-life’. For instance, atorvastatin takes 15 to 30 hours before its concentration in your blood is reduced by half. In contrast, simvastatin takes only 2 to 3 hours before its concentration in your blood decreases. This means simvastatin stays in your body for a shorter duration than atorvastatin and therefore may not be as effective at lowering blood cholesterol as atorvastatin. 

Images show pharmaniaga simvastatin 40mg, 20mg and 10mg respectively. These are the simvastatin given by most of the public hospitals and clinics. Image credit to MIMS Malaysia.

That is why if you are taking simvastatin, you should take it at night because that is when the body produces cholesterol and you would want to seize the 3-hour window for simvastatin to do its work before it is eliminated from your body. Whereas if you take atorvastatin, it does not matter if you take it in the morning or at night because it stays in your body for a long time.

Here are the elimination half-life of the common statins prescribed in Malaysia:

2. Statins reduce your cholesterol production at the liver.

Your body gets cholesterol via two channels: the food you eat and your liver. Your liver makes a significant chunk of cholesterol and releases it into the blood. Statins work by inhibiting hydroxymethylglutaryl (HMG) CoA reductase, an enzyme the liver uses to manufacture the cholesterol. Without this enzyme, the liver cannot produce cholesterol as effectively and therefore your blood cholesterol drops. 

It is estimated that statins can lower blood cholesterol by 20 to 60% , raises good cholesterol level by 5 to 10% and reduces triglycerides level by 10 to 23%. (UpToDate - Statins: Actions, side effects, and administration) These results are quite impressive when compared to other types of cholesterol-lowering medications. 

Image credit: https://www.medicine.com/condition/high-cholesterol

3. Statins are generally safe but not without side effects.

The most important side effect of statins is muscle injury. Clinically, it is known as the statin-associated muscle symptoms (SAMS). SAMS is not well-understood and the term SAMS is used to imply that these symptoms are not always truly caused by statin use. Nevertheless, recent scientific research has shed more lights on how statins may cause muscle injury. One of the more well-understood explanations is that statins reduce the production of Coenzyme Q10 (CoQ10), which plays an important role in muscle cell energy production. Read more about CoQ10 in our previous article here. 

You can prevent muscle injury by following your doctor’s instructions on taking your statins, as well as taking CoQ10 supplements. Consult a pharmacist when choosing a suitable CoQ10 for yourself. It will also be useful if you let your doctor know your muscle pain because it can also be caused by other reasons. If it is really the statins that cause muscle injury, your doctor would reduce the dose of your statin. Do not reduce your own dose without talking to your doctor first.

4.  There are branded and generic statins available.

Most people take statins for many years, and it can be a huge financial burden for people who do not have a high income level. A 20mg tablet of Lipitor^®, the branded atorvastatin, costs RM5 on average. In contrast, generic brands such as Tulip^® 40mg and Rotaqor 20mg cost only RM1.90 and RM3.20 each. You can learn more about branded and generic medicines here, but it is suffice to say that generic medicines are equally effective as branded medicines. Therefore, if you cannot afford your branded statins, check with your doctor or pharmacist to see if it is possible to switch to a cheaper, generic option. 

5.  Avoid taking certain medications and grapefruit juice with statins.

Statins can interact with many medications and grapefruit juice, which could potentially result in increased risk of side effects such as muscle injury. Consult your doctor or pharmacist by telling them the other medications that you are taking and they would know whether it is safe to take them with statins. 

Besides taking your statins according to your doctor’s instructions, make sure you also follow his instructions on eating your diet and doing exercises. Taking statins alone is not as effective as living a healthy lifestyle and taking your medications on time. Both are equally important in reducing your risks of cardiovascular diseases.

References

1. UpToDate - Statins: Actions, side effects, and administration

2. UpToDate - Statin muscle-related adverse events

3. American Heart Association - Cholesterol Medications

4. NHS - Statins

5. CPG Management of Dyslipidemia 2017

Cover image credit: https://www.everydayhealth.com/high-cholesterol/treatment/cholesterol-lowering-medications/

Written by

Ms Joyce Toh