Which statin drug is best?

I re-post a Heart Scan Blog post from one year ago, answering the question: Which statin drug is best?

I still get this question from patients in the office and online, nearly always prompted by a TV commercial. So let me re-express my thoughts from a year ago, which have not changed on this issue.

The statin drugs can indeed play a role in a program of coronary plaque control and regression.

However, thanks to the overwhelming marketing (and lobbying and legislative) clout of the drug manufacturing industry, they play an undeserved, oversized role. I get reminded of this whenever I'm pressed to answer the question: "Which statin drug is best?"

In trying to answer this question, we encounter several difficulties:

1) The data nearly all use statins drugs by themselves, as so-called monotherapy. Other than the standard diet--you know, the American Heart Association diet, the one that causes heart disease--it is a statin drug alone that has been studied in the dozens of major trials "validating" statin drug use. The repeated failure of statin drugs to eliminate heart disease and associated events like heart attack keeps being answered by the "lower is better" argument, i.e., if 70% of heart attacks destined to occur still take place, then reduce LDL even further. This is an absurd argument that inevitably encounters a wall of limited effects.

2) The great bulk of clinical data examining both the incidence of cardiovascular events as well as plaque progression or regression have all been sponsored by the drug's manufacturer. It has been well-documnted that, when a drug manufacturer sponsors a trial, the outcome is highly likely to be in favor of that drug. Imagine Ford sponsors a $30 million study to prove that their cars are more reliable and safer. What is the likelihood that the outcome will be in favor of the competition? Very unlikely. Such is human nature.

If we were to accept the clinical trial data at face value and ignore the above issues, then I would come to the conclusion that we should be using Crestor at a dose of 40 mg per day, since that was the regimen used in the ASTEROID Trial that achieved modest reversal of coronary atherosclerotic plaque by intravascular ultrasound.

But I do not advocate such an ASTEROID-like approach for several reasons:

1) In my experience, nobody can tolerate 40 mg of Crestor for more than few weeks, a few months at most. Show me someone who can survive and tolerate Crestor 40 mg per day and I'll show you somebody who survived a 40 foot fall off his roof--sure, it happens, but it's a fluke.

2) The notion that only one drug is necessary to regress this disease is, in my view, absurd. It ignores issues like hypertension, metabolic syndrome, inflammatory phenomena, lipoprotein(a), post-prandial (after-eating) phenomena, LDL particle size, triglycerides, etc. You mean that Crestor 40 mg per day, or other high-intensity statin monotherapy should be enough to overcome all of these patterns and provide maximal potential for coronary plaque reversal? No way.

3) Plaque reversal can occur without a statin agent. While statin drugs may provide some advantage in the reduction of LDL, much of the benefit ends there. All of the other dozens of causes of coronary atherosclerotic plaque need to be addressed.

So which statin is best? This question is evidence of the brainwashing that has seized the public and my colleagues. The question is not which statin is best. The question should be: What steps do I take to maximize my chances of reversing coronary atherosclerotic plaque?

The answer may or may not involve a statin drug, regardless of the subtle differences among them.

Comments (7) -

  • Anonymous

    2/8/2009 5:04:00 PM |

    For those with atherosclerosis, I would think the most important question is how to stabilize existing plaque to prevent emboli. Then worry about the minimal reversal that is possible. But perhaps the solution to both problems is the same.

  • Anonymous

    2/9/2009 3:58:00 PM |

    K1f6 can predict who will respond favorably to statins and who will not benefit. Available from Berkely Heart Lab and other places.  Dr Davis, do you test?

  • Rick

    2/17/2009 11:01:00 AM |

    It would be great if you could follow-up this post sometime with another version, where the question is interpreted as meaning something like: "My doctor and I have agreed that I should take Vitamin D, niacin, and fish oil, eat walnuts everyday, and get more exercise, and that I also need a statin to get my cholesterol down as quickly as possible. Which statin drug would be best?" This could help us understand some of those subtle differences you mention.

  • Anonymous

    7/27/2009 10:40:04 AM |

    Statins are good for cholestrol but really should only be used for at risk patients Drug Companies have encouraged statin use for more patients than is neccessary

  • Rick

    7/29/2009 5:09:36 AM |

    Thanks, Anonymous, I understand that point. But I'd like to find out, for people who do need statins, how the statins differ, how one fixes dosage, whether there are targets beyond which doctors should withdraw the drug or reduce dosage, and so on. Any pointers to that kind of info would be great.

  • buy jeans

    11/3/2010 8:27:47 PM |

    However, thanks to the overwhelming marketing (and lobbying and legislative) clout of the drug manufacturing industry, they play an undeserved, oversized role. I get reminded of this whenever I'm pressed to answer the question: "Which statin drug is best?"

  • Anonymous

    2/1/2011 12:09:18 PM |

    Some people have already had one or more heart attacks, and even statin sceptics seem to accept that these people can benefit from a statin. So it would be very useful if there were a post which actually compared statins from this point of view.