Amanda Wilde (Host): Welcome to UK HealthCast, a podcast presented by UK HealthCare. I'm Amanda Wilde. And my guest is Dr. Lucas Shelton, Medical Director at UK HealthCare Primary Care, Frankfurt. We're discussing statin therapy and exploring its impact and misconceptions. Dr. Shelton, welcome to the podcast. Thank you for being here.

Dr. Lucas Shelton: Thank you for having me.

Host: What are statins?

Dr. Lucas Shelton: Statins are one of the most commonly prescribed medications in our country. Statins are medication that block a certain part of the production of cholesterol molecules within the liver. The process that cholesterol molecules-- and there are many different types-- the process is very complex. But the place where statins block the production leads to a decrease in something that we'll talk about here in a bit, but what is commonly referred to as bad cholesterol called LDL. So, a downstream effect of statin is the reduction of LDL within the bloodstream.

Host: Now, a lot of us do have increase in LDL. I know I do. When do you actually prescribe statins? What are the circumstances under which a patient is qualified to get the statin therapy?

Dr. Lucas Shelton: As providers, when we think about who do we prescribe statins to, we have to categorize patients into two separate categories. The first main category is let's just talk about a hypothetical patient who, let's say for example, the patient has had a heart attack or a certain type of stroke. Those two events are what we call atherosclerotic cardiovascular events. Just the fact that that patient has had one of those events, no matter what the level of cholesterol or LDL is in the bloodstream, just the fact that that event has happened, statins have a clear benefit to reduce the chance of a future event and also reduce the chance of death, which we refer to as mortality in medical studies.

So, that's the first main category. It's patients who have certain conditions. Just to list a few more, so I mentioned heart attack and stroke. Other patients can have things like coronary artery disease. That's where cholesterol plaques have built up within the arteries that surround the heart. Blockages like that can cause things like chest pain and be a risk for future heart attacks.

But in terms of just a few other things, that can be an example of, "Okay, the patient has had this event. I need to get them on a statin if they're agreeable." Just another big example would be something that we call peripheral artery disease. That is where cholesterol plaques build up with within the arteries of either the arms or the legs, most commonly within the legs themselves. So, for anyone listening to this, that's the first big category. You've had this certain event, no matter what your cholesterol level is, you benefit from statin.

The next category, and this is just the second main category, is let's say another hypothetical patient meets with their provider and says, "Hey I've been thinking about statin. I've kind of seen it in the news with various different things. Should I be on a statin? I've never had a heart attack. I've never had a stroke. I've never been told I have blockages in my heart or in my legs or my arms. What should I do?"

As providers we have to think about for that patient, something called-- and it's quite a long term, but I'll break it down. And so, it's the atherosclerotic cardiovascular disease risk. So, it's your risk of developing within the next 10 years basically one of those events or one of those conditions that I just mentioned with the first category, how do we get a number of risk for patients who have not had those events? There's a calculator. It takes into account a lipid panel. What is a lipid panel? It's a routine blood work you can do with your primary care office.

As a primary care doctor, I check so many of these for many patients to help risk stratify patients who've not had events, but trying to answer that question, "Do they need to be on a statin?" The risk calculator takes into account many different aspects, age, the level of cholesterol that we draw out of the blood, focusing mostly on the LDL level, because that is the type of cholesterol that's most associated with the risk of those types of events I alluded to earlier: smoking status, history of diabetes. So, different things.

Once we plug the numbers in, the output is a risk usually anywhere between zero-- and I've seen some high ones before. But for the purpose of this discussion, let's start on the higher end of risk. So if I have a patient in that second main category, no previous events, and their risk comes out to be at least 20% or greater, that's considered to be high risk for a future event or a future atherosclerotic condition, that patient would benefit from a high intensity statin. The nuances of the dosing there, I think, is too detailed for this discussion. But that's a definite indication beyond.

There's an intermediate range of risk. The exact number of intermediate range of risk falls between 7.5% and just under 20%. What as providers do we do in that range? That can be also a nuanced discussion. In general, for patients who have at least a 10% risk and at least one other risk factor for cardiovascular disease, for example, high blood pressure, that's a good indication to be on at least a low-intensity statin.

Let's say you have an even lower range of risk within the intermediate range within 7.5 to 10. Again, it can be some nuance in the discussion between the provider and the patient on that decision. I think for someone listening to this podcast, I would want them to know that we have multiple things as providers we can use to help guide the patient through that decision if they are at low intermediate risk. There are imaging studies we can do. For example, one thing is called a coronary calcium score. That's a scan that looks to see how much calcium is built up in the arteries around your heart, and the calcium is often directly related to the amount of cholesterol molecules that have built up within the arteries around the heart. So, that's just one study we can use to help make that decision on would you benefit from statin. And then, there's some other advanced lab tests that we can do also to help with that decision.

A few other things we consider would be family history. If there's a family history of heart attacks or strokes at an early age, for example, 30s and 40s, and first-degree relatives, we take that into account. And then, the last bracket of risk that we consider is what's called borderline risk. That's from 5% to about the 7.5%. Really unique situations where sometimes there are indications for statins even in that range. But again, it's kind of a nuanced discussion and that would be on us as providers to guide the patient through that decision-making process.

Host: So, this is where it really pays off to partner with your doctor because you have a lot of good screening tools with which to make recommendations regarding statins. And with all these benefits, reducing the molecule that makes the bad cholesterol, reducing the possibility of future events like heart attack or stroke, what are the downsides or possible side effects of statins?

Dr. Lucas Shelton: The most common side effect of statin medications has to do with muscle and muscle tissue specifically. Data has shown within studies that about 5% of patients who take statins will experience muscle aches or muscle cramps or muscle pain, we call those myalgias.

In clinical practice, over time, up to 10% of patients can experience these muscle cramps. Overall, I tell my patients that I'm confident at least 90% confident that you will not experience muscle side effects. I always tell my patients on the front end that they are possible, but I try to set the expectation that it is most likely that they will not experience the muscle side effects from statins. There's a much more rare muscle side effect that has to do with even some muscle breakdown from the statin itself. If that ever were to happen, and it's much more rare than even just the muscle pain itself, we always just stop the statin. And there are certain things we can look for as clinicians to know when to suspect that that is happening. But by and large, in terms of muscle side effects, statins are very well tolerated.

A few other side effects that statins can have, and there are honestly not many. There is literature and it is prevalent in literature, it's a modest risk-- and in my opinion, very modest-- of the development of new onset of diabetes. The risk is 0.2% per year. And when I was preparing for this talk today, I think the best way I want to explain how I would think about that risk is this hypothetical situation. So, let's say I'm establishing care with a patient. And I do routine labs. I check their cholesterol. I screen them for diabetes, which is a routine thing we do for most patients. Let's say the patient's labs come back and they have pre-diabetes and they're almost to the cutoff for diabetes, and let's say their cholesterol levels that I draw out of the blood suggest based on that risk factor or the risk calculation that I alluded to earlier they have a high enough risk to where I want to start the on a statin.

So, I think the question would be for that patient who theoretically almost has diabetes, but they have a high enough risk in terms of cardiovascular disease to be on a statin. Would I ever let that patient almost having diabetes stop me from prescribing a statin? And my short answer is absolutely not. The potential cardiovascular benefits of being on a statin for that patient far outweighs that 0.2% risk of developing diabetes.

And the thing I want to also add to that is, speaking for my practice, and I think it's good practice, is as I'm starting a statin, I'm not completely relying on the statin to reduce the patient's cardiovascular risk. I'm also talking with a patient about, "Hey, I want you to have a goal of 30 minutes of cardiovascular aerobic and some weight training exercise per day. I want you to decrease your saturated fat and trans fat intake and also decrease your processed carbohydrate intake." So, it's a combination of lifestyle matters along with starting the statin, not completely relying on the medication, even though it's a very useful tool. So, I think about that much more, the benefits rather than this very small risk of developing diabetes.

And on that note, let's say established care with a patient who already has diabetes and is at least 40 years old and not on a statin, diabetes in itself is such a risk factor for the things I mentioned earlier: heart attack, stroke, coronary disease, peripheral artery disease. That patients who have diabetes, no matter what their cholesterol levels are, they benefit from being on a statin. And so, patients who have diabetes who are at least 40, the dose that they would need to be on of a statin, that'd be a discussion with their provider.

So going back to your original question, very small risk of diabetes development. We've talked about the muscle side effects. And then, really, the only other, I guess, relevant side effect to even consider would be-- and this is very rare as well-- severe liver damage. This is so rare that what I do in my practice when I'm initiating a patient on a statin, I make sure they have normal liver function tests before I start the statin. But otherwise, I just make sure the patient is tolerating the statin after they've been on the statin.

Are there certain liver conditions and certain stages of liver disease where you don't want to do a statin? Yes. But that's the responsibility of the provider to know that. And going back to the initial thing I mentioned as far as the liver, the severe liver toxicity from statin, there is a 0.001% chance of that happening. So, almost non-existent. So, those are the three main side effect considerations.

Host: Are there any particular groups who might not benefit from or should avoid statin use?

Dr. Lucas Shelton: There can be patients who do have those rare side effects of muscle cramps, muscle breakdown. Let's say they start one statin. They get some muscle cramping or muscle pain, they try another. As providers, we've talked about another statin we could try that might have a lower chance of causing those side effects. The patient tries that one, some patients do. And that patient on the second statin does have the same side effects. That patient can have a true intolerance to statin. So, those patients, you know, we'd want to, in general, stay on statin. But again, I want to emphasize that that is truly is rare.

Thinking otherwise on who should avoid a statin, I think I go back to if the patient fits in that risk category or if they have the event category to where the provider is suggesting a statin. I cannot think of other reasons that-- at least initially-- we would want to avoid it. Now, there can be some other nuanced elements of this conversation. Let's say the patient is on other medications, there can always be medication interactions.

So, I think, as a followup answer to that question, yes, there can be certain instances. But again, I go back to that is the responsibility of it speaking for myself, me as a provider to recognize, "Okay, do you have a unique situation where maybe I should stay away from a statin?" But overall, I think, the message is that those are rare.

Host: Yeah. And it sounds like the treatment is highly individualized and we're being more general here. I think it's also interesting that you mentioned-- do I understand correctly that lifestyle changes can complement the effects of statin therapy in managing cholesterol?

Dr. Lucas Shelton: Absolutely. And there's evidence to show that patients who have cardiovascular exercise with having aerobics and having resistance training with weights at least 30 minutes a day, at least five days a week, reduces cardiovascular events and outcomes. So when I'm talking to a patient, and this is my job as a primary care doctor, is to talk with my patients about these matters. I emphasize that, as a doctor, I have tools to provide you as a patient. I have medications I can talk to you about. I have lifestyle changes that I can suggest to you. And in my mind, I think of it all as an additive effect in reducing bad outcomes for my patients.

Host: I have always had a vague idea that statins are risky, but I've learned today that statistics say no. Are there any myths like that or misconceptions like I had about statins that you frequently encounter?

Dr. Lucas Shelton: Yes, I think there are other misconceptions about statins that are common within our society. Just to name a few, one thing that I've heard most commonly, at least speaking from my own practice, I know this has been studied in literature, is there a risk of dementia from statin therapy? No is the short answer. There's no evidence to suggest that statin therapy increases the risk of dementia or of cognitive impairment. And cognitive impairment is basically just an alteration in the thinking pattern of patients and the thought processes. They can have many different causes, but statins do not cause dementia or the cognitive impairment.

A few other, I think common misconceptions of statin therapy can be kidney side effects. There is no evidence that statins have any effect on kidneys. When I was preparing for this talk, the literature suggested development of cancer from statin therapy can be something that is suspected to be a cause-effect relationship. It is not there. There is no causation of cancer from statin therapy. So, those were a few that I just saw in my kind of preparation for this talk. But overall, those things I just mentioned don't have any evidence to back them up.

Host: We don't know how these rumors get started sometimes.

Dr. Lucas Shelton: Yeah, it's hard to say. But I always tell my patients, if you see anything out in the community, if you talk to somebody who tells you these things. It's never my job to tell the patients they're wrong, it's just to have a conversation to try to get on the same page and share with my patients, you know, in a loving way what I think is best for them. But I just welcome those conversations with my patients. And personally, I think it's part of my job as a primary care, is to debunk things that are not true and, in a loving way, just tell my patients, "Hey, I think you would benefit from this. Let's talk about getting the therapy going for you."

Host: Well, Dr. Shelton, thank you for your insights and for this very thorough introduction to statin therapy.

Dr. Lucas Shelton: Well, thank you for having me. Statins are so prevalent within our country and a lot of people are on them, and a lot of people still might need them that are not on them and could benefit from them. So really, I'm thankful for this opportunity to share what I know about statins and how good of a medicine I think they are for the right patient.

Host: Right. You've really shared some important facts as well as debunk some of the fictions about statin therapy.

Dr. Lucas Shelton: Yeah.

Host: That was Dr. Lucas Shelton, Medical Director at UK HealthCare Primary Care, Frankfurt. For more information, visit ukhealthcare.uky.edu. And if you found this podcast helpful, please share it on your social channels and check out the entire podcast library for topics of interest to you. Thanks for listening to UK HealthCast, a podcast from UK HealthCare.