A comprehensive new review on how to treat high cholesterol and other blood lipid problems suggests that intensive treatment with high doses of statin drugs is usually the best approach.
But some statins work much better for this than others, the review concluded, and additional lipid-lowering medications added to a statin have far less value. And medications, of course, should be considered after first trying diet, weight loss and exercise.
The review, published in the Annals of Pharmacotherapy, examined the range of treatment options for "dyslipidemia," or concerns about LDL cholesterol that is too high; HDL cholesterol that is too low; elevated triglycerides; and other issues that affect millions of people around the world.
It concluded that use of statin drugs, which effectively lower LDL, or "bad" cholesterol, is appropriate for both moderate and high risk patients who have issues with their cholesterol levels, or may already have experienced a heart attack or angina as a result of cardiovascular disease.
But it also found that in most cases simply increasing the statin dose would offer the best protection against serious cardiovascular problems, more so than using other drugs or combinations of drugs.
"Statins are proven medications that can reduce heart attacks and strokes by about 30 percent in the patients that need them," said Matt Ito, a professor of pharmacy practice at Oregon State University, author of the study and president-elect of the National Lipid Association.
"What we looked at here was whether adding other drugs or therapies to the use of statins could further reduce problems, and in most cases the research indicates that they didn't help," Ito said. "What did help was increasing the statin dose to higher levels within the range for which they are approved. And there did not appear to be a significant change in side effects based on any approved dosage."
The goal with what the researchers called "intensive monotherapy," or high doses of just one statin drug, was usually to reduce LDL cholesterol to 100 mg/dL or less - or 70 mg/dL or less for people who already have coronary disease, diabetes or other special risks. Failing that, the medication goal should be to at least cut the LDL level in half, Ito said.
For intensive monotherapy with an average patient, research indicates that only two of the most commonly prescribed statins are suitable: atorvastatin and rosuvastatin. Others that are "not suitable for intensive monotherapy," the review said, include fluvastatin, lovastatin, pitavastatin, pravastatin, and simvastatin.
All statin drugs, at lower dosages, can have value if less dramatic lowering of LDL levels is needed, the researchers said.
"The reaction to statin regimens varies with the individual, so some of these other drugs may also be able to accomplish the goals we're seeking," Ito said. "These recommendations are based on results with an average patient, but physicians may find some of their patients can do adequately well with other statins, or that they don't need intensive monotherapy."
Statin drugs are generally well tolerated but can be associated with some side effects, experts say, particularly myopathy, or muscle pain and damage. These are some of the factors considered in establishing safe and accepted dosages. Some of the available drugs at their highest accepted dosage have been shown to cut LDL levels more than others, Ito said, and are therefore the best candidates for intensive therapy.
Other medications sometimes given for dyslipidemia were shown to have less value or even pose additional risks, the review found. This includes fibrates to lower triglyceride levels; niacin to lower triglycerides and raise HDL levels; and omega-3 fatty acids that appeared safe, but added little in efficacy to what was already being accomplished with statin drugs.
"We found that only in patients with extremely high triglycerides and very low HDL would use of fibrates be appropriate to use in addition to statins," Ito said. "Otherwise the increased risks outweigh the benefits, especially in women."