What you should know about Statin Intolerance

Podcast Transcript

Announcer: Welcome to Love Your Heart, brought to you by Cleveland Clinics Sydell and Arnold Miller Family Heart and Vascular Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy.

Interviewer: Today I'm with Doctor Leslie Cho who's Section Head of Preventive Cardiology and she's also the director of our Women's Cardiovascular Center. Thank you for joining me today to talk about statin intolerance.

Dr. Leslie Cho: Thank you.

Interviewer: So a lot of patients feel that they cannot take statins.

Dr. Leslie Cho: No, absolutely. I think statin intolerance was a thing that was ignored by many physicians over the years, and it wasn't because of a malice but we never saw it trials, in large clinical trials. But when statins became widely prescribed, we started seeing it more. And statin intolerance is real and I don't need to tell you that because if you clicked on this link, you know, because you probably had muscle aches on statins. It's very common, five to 10% of patients have it. The thing with statin intolerance is that you can get muscle aches if you're on a cholesterol lowering medicine if you drink alcohol, if you are taking some cardiac medicines that can interfere with statins' ability to get out of the body.

So for example, there are medicines like antiarrhythmic medications for your AFib like amiodarone or Cordarone that can interfere with the statin elimination that can cause muscle aches. Diltiazem, which is a very commonly prescribed high blood pressure medicine can interfere. And so you have to be really be mindful and this is something that you and your primary care doctor have to really talk about and discuss. There are some herbal supplements that can exacerbate the muscle aches when you're on it. For instance, patients are on red yeast rice and they're on statins. Well, red yeast rice is a lovastatin, and so if you're on two statins, of course you're going to have muscle aches. So it's important to be mindful of everything you're taking and whether that's causing muscle ache.

Now many people have muscle aches on cholesterol lowering medicine and they're doing everything right and they're not on any medicines. Now for those patients, we think about a couple of things. One is that statins, there are two types of statins, one is called hydrophilic, and one is called lipophilic. The hydrophilic statins are less likely to go to your muscles, and if you really are intolerant then we try to switch you to the hydrophilic statins, and those are pravastatin and rosuvastatin, otherwise known as Crestor or Pravachol. And they are more gentle on the muscle. If you really have severe muscle aches ... And the muscle ache we're talking about is not like little aches here or there, but it's both sides of your body in big muscle groups, so in your arms or your back or your shoulder, your thighs or your buttocks, but both sides, not one side. Patients commonly say that they feel really sore and achy like they worked out in the morning and then it doesn't go away throughout the day. So they have that kind of soreness, that achiness throughout the day.

So if you have those symptoms, we want the symptoms to completely go away. Then we start you on a once a week cholesterol lowering medicine. If you're able to tolerate once a week, then we go to twice a week, Monday and Thursday. If you're able to tolerate for a couple of weeks, then we either increase the dosage or we increase how many times you take it in a week until you have symptoms or we get you to the adequate cholesterol control.

Interviewer: So a lot of patients will ask, "Well, why do I even need to be on a statin? Can't I just do medication or the herbals"

Dr. Leslie Cho: Yeah, yeah. No, that's a great question. So unfortunately, there has been zero herbal medicine that have been tested in terms of cardiovascular outcome. These cholesterol lowering medicine statins have been tested in over half a million people and they have had amazing reduction in cardiovascular risk reduction, which means less death, less heart attack, less stroke, less hospitalization, less need for bypass or a stent. And so for people who've had a heart attack or people who've had bypass surgery or a stent, there is no medicine quite like this. So you have to take this or something like this.

Now, let's say you can't take anything, the great news in 2018 is there is an alternative and the alternative is this PCSK9, which is an injection. But even with the injection, if you can take once a week or twice a week statins and not have symptoms, that's still really a good thing and we want you to be able to derive the benefit of statin therapy.

Interviewer: So you probably hear patients ask this. There's almost a fear of statins too.

Dr. Leslie Cho: Yes, yes, yes.

Interviewer: People are afraid they're going to get other conditions related to the statins. What do you tell patients?

Dr. Leslie Cho: So, we tell them that these are incredibly safe. They do not cause cancer. They do not cause dementia. It's been around since the late 80s and they are incredibly, incredibly safe. They do bring on the onset of diabetes earlier, they don't cause diabetes, but if you are prone to it, they bring it on earlier. But it's an incredibly safe drug and the benefit of taking these medicine far outweighs the risk of taking these medicines. I understand people not wanting to take medicine, because I don't want to take medicines either, but the goal of treatment is not to have a heart attack, stroke or death. How we get you there is details, but we have to focus on the goal, which is not to have a heart attack, stroke or death. And these medicines can really deliver in that regard. If you can get your bad cholesterol to less than 70, have a reduction in your inflammation, then great, wonderful. But most people cannot.

Interviewer: So that's the goal really. When do you start somebody on a statin, and then how do you monitor them?

Dr. Leslie Cho: So for secondary prevention, which is people who have had heart attack, or stroke or a bypass surgery or a stent, they have to be on a cholesterol lowering medicine. These statins are lifesaving. And so there's no doubt in my mind you have to be on a statin. For primary prevention, so people who's never had any heart disease, we think about starting medicine based on their risk. And so we do these risk calculations. We always start with diet and exercise and then if they don't get reduction and if their risk is still very high, then we start them on a cholesterol lowering medicine. But this is like a very personal thing we discuss. If you are morally opposed to a cholesterol lowering medicine, what can I do?

I think the one really important message is, in the era of Internet, there's a lot of bad messages out there. Anybody can put anything out there. It's really important to look at various sources. Look at who's talking. The American Heart Association is trustworthy. The American College of Cardiology is trustworthy. We're trustworthy. It's important to look at your source and to weigh all the data and then talk to your doctor. It's really, really crucial to remember the goal of treatment. Not fixate on pills, not fixate on like, "Oh my God, I'm on a pill. That means I'm getting older." But to fixate on the goal. We want you to live a long time. We want that to be a high quality life years. We want you to not be in heart failure. These are such important goals.

Interviewer: And just to end this discussion, what would you tell people that have been told they're statin intolerant or they think that they're statin intolerant?

Dr. Leslie Cho: So, if you think you're statin intolerant or you've been told and you don't think that they have done a thorough evaluation, it's important to come to a place like the clinic, Cleveland Clinic, where we can do a thorough assessment. Seek a second opinion. If you feel like you are truly statin intolerant, you failed the intermittent dosing, then talk to your doctor about these new drugs that are out there that can really be life-changing for you.

Interviewer: Well, thank you very much for spending time with us today and we appreciate all the information that you've provided.

Dr. Leslie Cho: Thank you so much.

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