Should You Go on a Statin (or a different type of cholesterol medication)? Why Cholesterol Is About More Than Just LDL
The question of whether or not to start a statin, or another type of medication to treat high cholesterol, is not a simple one.
It requires individual investigation, a thoughtful risk-benefit analysis, and an in depth conversation with a practitioner who is willing to look at your whole picture. Medications can be appropriate and helpful for many people. They can also be prescribed too quickly when the only number being considered is LDL.
And LDL alone does not tell the whole story.
Go Deeper
A standard lipid panel may be useful but is not enough information on which to base the decision about whether or not to start medication. Before deciding whether or not medication is the right next step, I want to know more.
A few additional markers can are essential:
ApoB
ApoB is emerging as one of the more revealing markers in cardiovascular disease risk assessment because it reflects the actual number of atherogenic - read plaque producing - particles in the blood. Said another way: LDL tells us something, but ApoB may tell us more about the actual number of particles capable of contributing to plaque.
Lipoprotein(a), or Lp(a)
Lp(a) is largely genetic. It can help identify inherited cardiovascular disease risk that may not be obvious from a standard cholesterol panel.
LDL particle information
Not all LDL particles are bad. They differ in terms of concentration, size, and effect on risk. It is helpful to know the LDL-C which measures the total amount of cholesterol carried by LDL and LDL-P which counts the actual number of LDL particles. You can have a normal LDL-C and a high LDL-P which may be dangerous, but even all high LDL-Ps are not the same, because large, buoyant particles may pose less risk.
Cholesterol is not just about what you eat
The bulk of cholesterol in the body does not actually come from food. It is made in the liver.
People can have elevated cholesterol for different reasons. Some people overproduce cholesterol while others overabsorb cholesterol. These mechanisms of high cholesterol are different and require different interventions.
This is one reason why people being started on statin for elevated LDL may be suboptimal treatment.
Cardiovascular disease is metabolic, too
Cholesterol is only one risk factor for cardiovascular disease. Metabolic disease may in fact be the biggest contributor to developing cardiovascular disease.
Metabolic disease is evaluated by:
Testing fasting insulin, fasting glucose, hemoglobin A1C
Evaluating blood pressure
Evaluating inflammation
Measuring body composition
Assessing family history
Assessing personal history
Assessing lifestyle factors including sleep, stress, movement, alcohol, and nutrition
If we are trying to understand cardiovascular disease risk, we need to understand the metabolic terrain in which cholesterol exists.
Imaging can clarify the decision
If LDL is elevated, and especially if there are additional risk factors, imaging can be helpful.
A coronary calcium score is a noninvasive test that looks for calcified plaque in the arteries of the heart. The presence or absence of actual plaque buildup informs a conversation about treatment options.
For some women, soft plaque may be an important part of assessing risk as well. A coronary CT angiogram can evaluate more of what is happening in the arteries. A CT angiogram requires an IV with contrast medium.
The goal is not to order every test on every person. The goal is to make decisions from a place of knowing as much as is reasonable and relevant.
Is a statin the right choice?
If, after looking at family history, personal history, advanced lipid markers, metabolic markers, and imaging, a statin appears to be the best course of action, then the next question is: which statin, at what dose, and how well is it tolerated?
Not everybody tolerates statins well. Some people do beautifully. Some people have side effects. If you decide to try one, give yourself time to see:
Is it tolerated?
Is it effective?
Are your markers improving?
Are there new symptoms?
Does the benefit outweigh the risk for you?
Assess and reassess. You can always change your mind.
What about the risks?
Every medication has risks and benefits. One known concern with statins is that they may increase blood sugar and the risk of developing type 2 diabetes in some people.
This brings us right back to the metabolic picture. Consider whether insulin resistance, glucose dysregulation, or an elevated hemoglobin A1C are already part of the story. If so, the decision making is even more nuanced and personal.
What can be tried before medication?
There may be intermediary steps worth considering before going directly to medication, or alongside medication if it is needed.
The following interventions can be considered depending on the individual and with the guidance of her practitioner:
Omega-3 fatty acids
Berberine
Niacin
Addressing insulin resistance
Increasing fiber
Reducing alcohol and processed foods
Resistance training
Improving sleep
Supporting gut health
Clarifying whether someone is an overproducer or overabsorber of cholesterol
Individualized care is of the utmost importance as is follow-up testing to document the effectiveness, or ineffectiveness, of interventions.
The bottom line
If your practitioner is recommending you start a statin based on LDL only, ask for more information.
Consider asking your clinician about:
ApoB, Lp(a), and LDL particle testing
Fasting insulin, glucose, and A1C
Coronary calcium score, when appropriate
Taking into consideration any relevant personal health history and family history of cardiovascular disease
The risks and benefits of medication for you
A statin can be the right tool. It is just not the only tool and is best prescribed when a thorough, personalized evaluation has been completed. The goal is to make the most informed, individualized decision possible.
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As with all of my articles, blogs, social media posts, etc, this article is educational and not a substitute for medical care. Please check with your clinician before changing your routine.