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Your Guide To Choosing A Statin Drug

By: Allen Douma, M.D., for AARP. Published with permission of the author. Source: AARP.org Date Posted: 2003-10-15 12:27:00-04:00

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Note: The conclusions of the Oregon Health Resources Commission represent findings, at the time the report was written, for most people taking a statin drug. However, these findings may not necessarily apply to a given individual. You should discuss these findings with your health care providers, to determine which (if any) drug is best for you.

Table of Contents

• Summary
• Background
• Legislative Mandate
• The Review Process
• Individual Differences
• Drugs Reviewed
• Conclusions

Summary

With the growing number of new drugs, it's more difficult for a person or their health practitioners to decide which medication best fits an individual's needs.

And, with a wide variation in the cost of drugs used to treat the same medical problem, such as lowering cholesterol, it's hard to judge whether a higher priced drug is better or not.

To help overcome this challenge, legislation was passed in Oregon directed at evaluating the relative effectiveness and safety of similar medications. The resulting information can help you and your health practitioners make more informed decisions about which drugs you take and perhaps lower the cost.

As part of this process the Oregon Health Resources Commission (HRC) compared the effectiveness and side effects of "statin" drugs in the treatment of high LDL cholesterol (which is associated with a higher risk of heart disease), heart disease, and stroke.

The HRC appointed a subcommittee, which reviewed a study done by the Oregon Health and Science University's (OHSU) Evidence-based Practice Center. The subcommittee also solicited public input from any interested party, including pharmaceutical companies.

The HRC subcommittee used all the input to make conclusions comparing how well the drugs work and the safety of these medications. All of the meetings of the subcommittee were open to the public.

In evaluating the statin drugs, the HRC reviewed the medical studies on atorvastatin (available as brand name Lipitor), fluvastatin (available as brand name Lescol), lovastatin (available as generic Lovastatin and brand name Mevacor), pravastatin (available as brand name Pravachol) and simvastatin (available as brand name Zocor).

Major conclusions of the subcommittee were that:

1. Although a main goal of the process was to find the most effective and safest statin drug for lowering cholesterol and preventing disease, no one statin was found to be better than the others.
2. No evidence indicates that there are any differences among the statins with regard to negative side effects in groups of people based on race, ethnicity, age, gender, or in people with diabetes.
3. Three of the statins - lovastatin (generic Lovastatin and brand name Mevacor), pravastatin (Pravachol), and simvastatin (Zocor) have been shown to improve coronary heart disease outcomes, but there is not enough evidence to conclude this for atorvastatin (Lipitor) and fluvastatin (Lescol).
4. Although the evidence does not demonstrate that there is a difference between lovastatin (generic name Lovastatin and brand name Mevacor), pravastatin (Pravachol), and simvastatin (Zocor), the evidence is not strong enough to say that differences do not exist.
5. Although the evidence shows that lowering LDL cholesterol lessens the chances of heart disease, greater lowering of LDL cholesterol does not necessarily mean even better outcomes.

Background

There are many statins now used to lower LDL cholesterol, which is associated with a lower risk of heart disease. These drugs are also called "HMG-CoA reductase inhibitors" because of what they do chemically in the body.

When a person and their doctor decide that taking a statin is the best choice to reduce the risk of heart disease and stroke, they still need to decide which one to take.

But health practitioners and the general public have had little to no access to information about how one statin compares to another. This has been true with regard to both how effective they are and how the side effects compare.

A major reason for this is that most drug research in humans is done primarily to show whether a particular drug is safe enough and effective enough to be approved by the FDA. These studies usually just compare the drug to a "sugar pill" or placebo rather than to another drug already available to treat the condition.

As consumers, we are used to having access to trustworthy information to help us make informed choices. For example, in order to choose a car many people turn to an unbiased source of information such as Consumer Reports. Until now there was nowhere to go to find this type of comparison of how different drugs treat a particular disease or medical condition.

Analyses such as those on this website are finally giving consumers and their health care providers information they can trust to help them determine which drugs are more effective and which ones have fewer side effects.

Legislative Mandate

The Oregon legislature and the Governor's office are charged with ensuring that enrollees in the state's health plan receive the most effective services at the best price. To meet this goal, in 2001 the Oregon legislature passed a bill that called for extensive review of medical studies to determine, where possible, which medications are the most effective and safest in treating specific diseases or conditions.

This review process is ongoing, and the subcommittee will use additional medical studies, as they become available, to re-evaluate, update, and modify conclusions as appropriate.

The Review Process

The Oregon Health Resources Commission appointed a special subcommittee to advise them in evaluating statin drugs. The chairperson was a pharmacist. Other members included an internist, a pharmacist, a chemist, a family practitioner, an attorney, and patient advocates.

In order to compare statin drugs in lowering cholesterol and decreasing the risk of disease or death as well as to compare the negative side effects, the subcommittee asked the OHSU Evidence-based Practice Center to search the medical literature to answer a set of questions the subcommittee had developed.

The subommittee then evaluated the research data and public comments submitted during a series of meetings, all of which were open to the public.

In their review the subcommittee paid particular attention to the effects of these drugs on:

• LDL cholesterol levels,
• risk of heart pain due to coronary heart disease,
• heart attacks,
• stroke,
• the need to reopen arteries of the heart, and
• death.

Subcommittee members also evaluated these medications for safety and negative side effects. The subcommittee paid particular attention to damage of muscle and liver cells and the risks in someone being treated for HIV or with an organ transplant.

Individual Differences

It's important to note that medical studies evaluate the overall effects of a drug on a group of people. Even when a study doesn't show that a whole group is helped or hurt, typically some people are helped and some people are hurt.

In choosing to recommend medical treatments to an individual, health practitioners consider that person's individuality including her or his medical history. You can use the conclusions presented here as a good foundation to start a discussion with your health practitioner(s) about what's right for you.

Drugs Reviewed

• The following statin drugs were included in an extensive review of the medical literature:
• Atorvastatin (available as brand name Lipitor),
• Fluvastatin (available as brand name Lescol),
• Lovastatin (available as generic Lovastatin and brand name Mevacor),
• Pravastatin (available as brand name Pravachol), and
• Simvastatin (available as brand name Zocor).

Conclusions

While the conclusions of the Oregon Health Resources Commission represent findings for most people taking one of these drugs, these findings may not necessarily apply to a given individual. You should discuss these findings with your health care providers, to find out which (if any) drug is best for you.

If you are taking a medication or deciding to take one, ask your doctor and pharmacist three simple questions:

1. Are there other drugs that are used to treat my condition?
2. If there are, how do other drugs compare to this one, for me?
3. If two or more drugs are equally effective and safe, how do the prices compare?

Major conclusions of the HRC subcommittee were that:

1. Although a main goal of the process was to find the most effective and safest statin drug for lowering cholesterol and preventing disease, no one statin was found to be better than the others.
2. No evidence indicates that there are any differences among the statins with regard to negative side effects in groups of people based on race, ethnicity, age, gender, or in people with diabetes.
3. Three of the statins - lovastatin (generic Lovastatin and brand name Mevacor), pravastatin (Pravachol), and simvastatin (Zocor) have been shown to improve coronary heart disease outcomes, but there is not enough evidence to conclude this for atorvastatin (Lipitor) and fluvastatin (Lescol).
4. Although the evidence does not demonstrate that there is a difference between lovastatin (generic name Lovastatin and brand name Mevacor), pravastatin (Pravachol), and simvastatin (Zocor), the evidence is not strong enough to say that differences do not exist.
5. Although the evidence shows that lowering LDL cholesterol lessens the chances of heart disease, greater lowering of LDL cholesterol does not necessarily mean even better outcomes.

Specific conclusions of the subcommittee were:

1. All five statin drugs were able to reduce LDL cholesterol by at least 40 percent. Atorvastatin (Lipitor), lovastatin (generic Lovastatin and brand name Mevacor), and simvastatin (Zocor) were studied at higher doses, resulting in a reduction of LDL cholesterol of 41 percent to 49 percent. Atorvastatin (Lipitor) was studied at even higher doses, which resulted in a lowering of LDL cholesterol of greater than 50 percent.
2. There is good evidence that lovastatin (generic Lovastatin and brand name Mevacor), pravastatin (Pravachol), and simvastatin (Zocor) reduce heart and blood vessel disease.
3. There is not enough evidence to conclude what effect atorvastatin (Lipitor) or fluvastatin (Lescol) have on improving heart disease.
4. Although the evidence shows that lowering LDL cholesterol lessens the chances of heart disease, greater lowering of LDL cholesterol does not necessarily mean even better outcomes.
5. Statins are equally effective in men, women, and the elderly. There is no evidence about whether statins are more or less effective in any other subgroup based on race, ethnicity, or specific medical problem.
6. There are no data about whether any of the statins have more, or more serious, side effects in men, women, the elderly, African-Americans, or people with diabetes.
7. It ' s important to consider the possibility of negative interactions of statins with other drugs used by people with organ transplants or HIV.
8. There is not enough evidence to show that any of the statins cause more liver or muscle damage than any of the other statins.