Statins: Types, uses, side effects, and alternatives

If your doctor wants you to take a statin for high cholesterol, you're not alone. More than 40 million Americans take them, too. In fact, statins are the most prescribed drugs in the U.S.

But you may have questions. You may be wondering about side effects of statins, types of statins, how statins work, and what your doctor may prescribe instead of statins to help lower your cholesterol.

What are statins?

Statins are prescription drugs you take as pills to lower cholesterol. Cholesterol is an essential component of cell membranes. However, when you have too much, it can build up inside the walls of your arteries. This is called plaque. Cholesterol-laden plaque contributes to heart disease in different ways.

A buildup of cholesterol can make your arteries narrow and even block them. If a cholesterol plaque ruptures, a blood clot forms there and this can lead to a heart attack or stroke. Cholesterol also provokes inflammation in the arteries, which can contribute to the formation of artery-blocking clots.

Sometimes, just changing what you eat and being more active can lower cholesterol. But if your cholesterol stays high, you may need a statin or other cholesterol-lowering medication.

How do statins work?

Statins interfere with how your liver makes cholesterol; most importantly, LDL, the "bad" kind. Triglycerides are a second kind of cholesterol that can contribute to plaque buildup. HDL has traditionally been referred to as the "good" cholesterol because it helps your body get rid of LDL. However, changing HDL has not been seen to reduce the risk of heart disease, so this is no longer a focus of cholesterol management.

Statins work to lower LDL levels. This slows the buildup of cholesterol in your arteries.

Statins also reduce inflammation in artery walls. If you do have plaque buildup inside your arteries, statins can help prevent them from breaking open and leading to blood clots.

Once you start taking a statin (or any cholesterol lowering drug), you probably will stay on it for life. If you stop, your protection from the statin will wear off.

Who might benefit from statins?

You may benefit from statins if you

• have high LDL cholesterol levels
• have had a heart attack or stroke, or are at risk for having one
• have diabetes (a risk factor for heart disease) and are over age 40.

Statins may help you live a longer and healthier life. But the degree to which you may benefit can vary. Your doctor can tell you about your personal risk and how much benefit to expect.

People who are pregnant or who have liver disease should not take statins.

What types of statins are available?

Eight statins are approved by the U.S. Food and Drug Administration (FDA):

• atorvastatin (Lipitor)
• fluvastatin (Lescol)
• lovastatin (Mevacor)
• lovatstatin extended release (Altoprev)
• pitavastatin (Livalo)
• pravastatin (Pravachol)
• rosuvastatin (Crestor)
• simvastatin (Zocor).

Your doctor picks which statin may work best for you by considering a few things. They include how much you need to lower your LDL by, and other medicines you are taking. Sometimes people will have a side effect with one statin but are able to tolerate another one.

What are possible side effects of statins?

More than three decades of research have shown that statins are safe and effective. But like all drugs, statins can have side effects.

The most common side effects of statins are muscle aches and feeling tired. Other side effects that aren't as common are headaches, constipation, diarrhea, and sleep problems.

A 2022 study published in The Lancet reviewed the records of over 150,000 people in randomized trials of statins, and analyzed those who had muscle aches after taking statins or placebo. The study found that more than 90% of those symptoms were not related to the statins. The researchers concluded that the risks of muscle problems are low compared to the health benefits of statins.

How can I manage side effects of statins?

Muscle soreness is the main reason why people want to stop using statins. Studies have evaluated many therapies for resolving statin muscle aches, including vitamin D, and coenzyme Q₁₀, but have not found compelling evidence that any of them are effective.

In many cases, side effects will go away as your body gets used to the statin. If they don't, your doctor may suggest switching to a different statin or taking a lower dose, and sometimes taking the low dose every other day, for example.

What alternatives to statins might my doctor prescribe?

Some people just can't tolerate the side effects of statins. Others still have high cholesterol even after taking statins for a while.

Fortunately, there are different drugs to try and other ways to lower cholesterol.

Non-statin drugs

There are many classes of drugs to help lower cholesterol. These include ezetimibe (Zetia), bempedoic acid (Nexletol), and bile acid sequestrants, which have been seen to lower the risk of heart attack and stroke.

Ezetimibe reduces the amount of cholesterol your body absorbs from food (or reabsorbs from what the liver releases). Large, randomized studies did not find any difference in side effects of ezetimibe compared with placebo.

Bempedoic acid blocks the production of cholesterol in your liver, but the medication does not get into muscle cells, so it can be an effective option for people who have had problems with statins. It can be taken alone but is usually taken with other cholesterol-lowering medications. Side effects include gout (especially in those with a history of gout), mild worsening of creatinine (a measure of kidney function), and gallbladder inflammation (cholecystitis).

Bile acid sequestrants stop bile acid in your stomach from getting absorbed in your blood. Your liver then takes the cholesterol from your blood to make the bile acid it needs. Side effects include constipation, heartburn, nausea, diarrhea, and muscle pain.

PCSK9 inhibitors

PCSK9 inhibitors are a newer type of cholesterol drug. These medicines are for people who have an inherited condition that causes very high levels of LDL. They also are for people with heart disease whose cholesterol has not been sufficiently lowered with a maximum dose of statins.

PCSK9 inhibitors work by helping the liver remove cholesterol from the blood. PCSK9 is a naturally occurring protein that breaks down certain receptors in the liver that remove LDL from the blood as it passes through the liver. By reducing the number of these receptors, PCSK9 increases the level of LDL in the blood. By hampering PCSK9's ability to work, PCSK9 inhibitors allow more LDL receptors to remain active in the liver. With more receptors to sweep away LDL, a person's blood levels of LDL drop. These drugs are given by injection and are more expensive than statin pills. Side effects include flulike symptoms and pain from the injection.

Nondrug ways to lower cholesterol

Some people can lower their cholesterol without medicine by making lifestyle changes. Those changes include having a healthy diet. The DASH diet from the National Heart, Lung, and Blood Institute is one example.

The DASH diet emphasizes fruits and vegetables, whole grains, fish and poultry, beans, nuts, and low-fat dairy products. It limits sugary drinks, sweets, and foods high in saturated fat, like fatty meats and full-fat dairy products.

If you are overweight, losing weight may lower your LDL. Having a healthy diet can help with that, too.

Another way to lower cholesterol is through regular physical activity. Aim for 30 minutes each day. Other things to try include managing stress and quitting smoking. Both of those have an effect on cholesterol.