If you have diabetes, there is a good chance that your doctor has recommended or at least discussed taking a type of medication called a statin. This is because heart disease is the leading cause of death for both men and women in the United States. Having diabetes makes it twice as likely that you’ll have heart disease or a stroke compared to someone without diabetes. And the longer you have diabetes, the more likely you are to have heart disease.
Statins
Statins are medicines that help to lower the LDL (“bad”) cholesterol and other fats, called triglycerides, in the blood. They work by blocking a liver enzyme, HMG-CoA reductase, that’s needed to make cholesterol. By lowering cholesterol, statins lower the risk of heart attack, stroke, and angina. The American Diabetes Association recommends statin therapy for people with diabetes as primary prevention in the following instances:
- For people aged 40 to 75 years without heart disease
- For people aged 20 to 39 years with additional heart disease risk factors
- For people with multiple heart disease risk factors or aged 50 to 70 years
- For people of all ages who have heart disease
The intensity of statin therapy will differ for these different groups of people, depending on age, number of risk factors, and presence of existing heart disease.
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When statins aren’t tolerated
Statins are usually well tolerated and safe. But, as with any medication, side effects can occur. Common side effects include:
- Myalgia (muscle aches and pain)
- Headache
- Nausea
- Weakness
- Sleep problems
Rarely, statins can cause a condition called rhabdomyolysis, which is when the muscle tissue breaks down. This can lead to kidney damage. Also, statins may increase the risk of diabetes in people with certain risk factors.
In many cases, a solution is trying a different statin or a reduced dose. But some people may still have side effects or choose not to take a statin. In these situations, other another cholesterol-lowering medication can be prescribed. Let’s looks at these other options.
Ezetimibe
Ezetimibe works by preventing absorption of cholesterol in the small intestine. It’s usually taken once a day with or without food. Ezetimibe can reduce cholesterol by 15% to 20%, and it may lower cholesterol further when taken with a statin.
Side effects include:
- Headache
- Dizziness
- Diarrhea
- Joint pain
- Fatigue
Rarely, ezetimibe can cause muscle pain or liver damage.
PCSK9 inhibitors
A new class of cholesterol-lowering medications are the PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors. PCSK9 is an enzyme that binds to LDL cholesterol receptors. PCSK9 inhibitors block this enzyme, which results in excretion of LDL cholesterol and lower blood LDL cholesterol levels. These medications are used if you have very high cholesterol levels and other medications aren’t working well enough, if you have side effects from them, or you are unable to take other medications for health reasons. They can lower LDL cholesterol by 45% to 70%.
Repatha (generic name evolocumab) and Praluent (alirocumab) are the two PCSK9 inhibitors available in the U.S. They are much more expensive than statins, and they are given by injection in the upper arm, stomach, or upper thigh, either every two weeks or every four weeks.
Side effects include:
- Back pain
- Symptoms of a cold or the flu
- Redness, bruising, or pain at the injection site
- Muscle pain
Fibric acid derivatives (fibrates)
Fibric acid derivatives are medicines that lower blood triglyceride levels by reducing the liver’s production of VLDL (very-low-density lipoprotein) and enhancing the removal of triglycerides from the blood. They also lower LDL cholesterol and raise HDL (“good”) cholesterol. Drugs in this class include fenofibrate and gemfibrozil. While they can lower triglycerides by 20% to 50%, they lower LDL cholesterol by just 10% to 15%. They can be taken with other cholesterol-lowering drugs, including statins.
Side effects include:
- Nausea
- Bloating
- Constipation
- Diarrhea
There is a slight risk of developing gallstones and rarely, rhabdomyolysis.
Bile acid sequestrants
Bile acid sequestrants work by binding to bile in the intestines, blocking bile acids from being absorbed in the blood. The liver then has to use cholesterol in the blood to make more bile acids, which results in lower blood cholesterol levels.
Bile acid sequestrants are taken in pill or powder form, once or twice a day (or more). Cholestyramine, colesevalam, and colestipol are examples of bile acid sequestrants. They can be used on their own or taken with a statin. On their own, they can lower cholesterol levels by 10% to 30%.
Side effects include:
- Constipation
- Diarrhea
- Bloating
- Heartburn
- Weight loss
- Sore throat
Other medicines are available to lower cholesterol levels. If you take a statin and have concerns or are having side effects, be sure to let your healthcare provider know. They may be able to change the dose or the type of statin that you take, as well as discuss other options that might be right for you.
Want to learn more about maintaining healthy cholesterol? Read “Natural Ways to Lower Your Cholesterol” and “HDL: Nine Ways to Raise Your Good Cholesterol.”
