For the past two weeks, we’ve been delving into various medications that are often prescribed for people with diabetes (see "The Ups and Downs of Meds and Diabetes (Part 1): Steroids" and "The Ups and Downs of Meds and Diabetes (Part 2): Blood Pressure"). Some of these drugs, such as steroids, have a direct effect on blood glucose levels. All drugs have some side effects, so it’s important to have a clear understanding of what these are. Over these next two weeks, we’ll look at classes of drugs that are used to lower cholesterol and triglyceride levels.
Statins: One of the most effective and powerful classes of drugs that can lower LDL (or “bad”) cholesterol are the statins. A major clinical trial has shown that statins can lower the risk of cardiovascular events in people with Type 2 diabetes by 37% and the risk of stroke by 48%. Since we know that people with Type 2 diabetes are at high risk for heart disease, these are pretty significant findings. Some health-care providers believe that statins should be routinely prescribed for everyone who has Type 2 diabetes, regardless of their level of LDL cholesterol.
Statins work in the liver by blocking a substance that makes cholesterol. They can also help the body reabsorb cholesterol that’s been deposited along artery walls, lowering the risk of blockage. Common statins include atorvastatin (brand name Lipitor), simvastatin (Zocor), fluvastatin (Lescol), pravastatin (Pravachol), lovastatin (Mevacor), and rosuvastatin (Crestor). The statins all work pretty much the same way, although the doses for each can vary. Statins also come in combination with other meds: Advicor (lovastatin plus niacin, a B vitamin that helps raise HDL, or “good,” cholesterol and lower LDL cholesterol and triglycerides), Caduet (atorvastatin plus amlodipine, a calcium-channel blocker that treats high blood pressure), and Vytorin (simvastatin plus ezetimibe, a drug that blocks the absorption of cholesterol).
Despite often being touted as miracle drugs, statins do come with their fair share of side effects. In some people, statins can increase liver enzymes. Mild increases are usually not of much concern, but severe increases can lead to permanent liver damage. Liver function tests (LFTs) must therefore be taken regularly if you take a statin. Statins may also cause a condition called myopathy, which is muscle pain, and a more serious condition called rhabdomyolysis in which muscle tissue breaks down. This condition can lead to kidney damage, as well. Any muscle tenderness or soreness you experience while taking a statin should be reported immediately to your health-care provider.
Fortunately, both liver and muscle problems are relatively rare occurrences with statins. Also, statins may have benefits that extend beyond just lowering LDL cholesterol. Some early evidence points to statins being helpful for preventing arthritis, bone fractures, and even Alzheimer disease. Statins may also be considered for helping to treat metabolic syndrome.
Selective cholesterol absorption inhibitors: This is a fairly new class of meds that works in the intestine, rather than the liver, to block the absorption of cholesterol. Ezetimibe (Zetia) is the first drug in this class to be approved. Ezetimibe primarily works to lower LDL cholesterol, but may also lower triglycerides and raise HDL cholesterol slightly. This med is sometimes prescribed to people who can’t tolerate statins.
Ezetimibe also comes combined with simvastatin in a drug called Vytorin. Side effects can include headache, dizziness, diarrhea, joint pain, and, less commonly, hives, rash, and difficulty breathing. A major study, called the ENHANCE trial, looked at the effectiveness of the combo med, ezetimibe/simvastatin, in reducing plaque build-up in artery walls. While the researchers concluded that this combo drug was no more effective than simvasatin alone in reducing plaque build-up, the combo drug did help lower LDL levels. Also, the study wasn’t large or long enough to make any firm conclusions. (For more about this study, see “Vytorin Study Results Disappoint.”)
If you take ezetimibe or the combo version, it’s worthwhile to talk to your health-care provider about the ENHANCE trial and to make sure that this drug is the best choice for you.
I should also add that, no matter what lipid-lowering drug you may be taking, you still need to follow the lifestyle recommendations of eating a heart-healthy diet, getting regular physical activity, and stopping smoking.
More on lipid meds next week!