Treating high cholesterol with statins

Statin medications lower cholesterol levels in your blood. This can reduce the chance of a heart attack, stroke, and premature death in people who have an elevated risk of developing heart disease or who already have it.

Statins work by blocking a liver enzyme needed to make cholesterol. The body needs some cholesterol to maintain good health. High blood levels of LDL cholesterol and low levels of HDL cholesterol are associated with an increased risk of arterial blockage throughout the body, which could eventually lead to heart attack, stroke, and peripheral artery disease in the legs. Statins may also moderately reduce triglyceride levels, decrease inflammation in arteries, and help raise HDL levels.

There are seven statin drugs, but they’re not all the same. Some statins are backed by stronger evidence than others that they lower cholesterol or reduce the risk of a heart attack or premature death from heart disease or a stroke.

Our recommendations about who should consider a statin drug to lower their cardiovascular risks are based in part on new guidelines from the American College of Cardiology and the American Heart Association. Previous strategies focused mainly on reducing elevated LDL or “bad” cholesterol to very low levels. But the new guidelines consider your overall risk of a heart attack or stroke in the next 10 years more important than LDL cholesterol levels alone. The guidelines determine your risk based on additional factors, including your age, blood pressure level, whether you smoke, are overweight, or have diabetes or other medical problems.

Diet and lifestyle changes, such as quitting smoking, losing weight if you need to, and exercise, can help lower your risk of heart attack and stroke. And in some cases, doing these can reduce your risk enough so that you don’t need a statin. Regardless of whether you take a statin or not, you should still follow them.

Statins can vary widely in cost—from as little as $53 per month to more than $600. Most people who take a statin must continue to do so for years—perhaps for the rest of their life—so the cost can be an important factor to consider.

Certain generic statins can cost as little as $4 for a month’s supply through discount generic programs run by major chain stores, such as Kroger, Sam’s Club, Target, and Walmart. For an even better bargain, you can buy a three-month supply for $10 through these programs. See the price chart below for the generic statins that are likely to be available through these programs.

The new guidelines recommend the following people consider a moderate-intensity statin (reduces LDL cholesterol by 30 percent to 50 percent)

• People 40 to 75 years old with an LDL level below 190 mg/dL but who have a high risk of heart attack or stroke of 7.5 percent or greater over the next 10 years.

Note: Our medical advisers say that if you fall into this category, you should consider a statin, but for some people, especially those with a 10-year risk less than 10 percent, diet and lifestyle changes could be the first step—those changes could lower your risk enough that you are no longer considered a candidate for a statin.

• Older than 75 with a history of heart disease or heart problems.

• At an increased risk of side effects from a high-intensity statin—this includes:

1. People older than 75, those with multiple and/or serious medical conditions, such as impaired kidney or liver function, those with a history of stroke or muscle disorders

2. People who currently use medications that could interact with statins

3. People of Asian heritage

The new guidelines recommend the following people consider a high-intensity statin (reduces LDL cholesterol by 50 percent or more)

• Anyone with a very high LDL cholesterol level—190 mg/dL or greater.

• People with diabetes between 40 and 75 years old who have a high risk of heart attack and stroke—greater than 7.5 percent over the next 10 years.

• People under 75 with a history of heart disease or heart problems.

Taking the evidence for effectiveness, safety, and cost into account, we have chosen the following statins as Consumer Reports Best Buy Drugs.

For people who need a moderate-intensity statin:

• Generic atorvastatin 10 mg or 20 mg
• Generic lovastatin 40 mg
• Generic pravastatin 40 mg 
• Generic simvastatin 20 mg or 40 mg

For people who need a high-intensity statin:

• Generic atorvastatin 40 mg or 80 mg

All of our Best Buys—atorvastatin, lovastatin, pravastatin, and simvastatin—have been shown to reduce the risk of heart attack and deaths from heart attacks, and are available as inexpensive generics. You could save more than $100 per month if you pay out-of-pocket, and you select a generic instead of a brand name statin.

Higher doses and high-intensity statins pose a greater risk of rare, but serious side effects, such as muscle breakdown that can lead to permanent kidney damage, coma, and possibly death. But some people—such as those who have very high LDL, have suffered a heart attack, or have diabetes—may require a high-intensity statin.

No matter which statin or dose you take, if you experience muscle aches and pains when taking a statin, contact your doctor immediately.

To save money, ask your doctor about splitting your statin pills. This can cut your costs substantially and is a widely accepted practice.

Cholesterol-lowering statins are used to help prevent heart disease, which can lead to heart attacks, heart failure, and death. Heart disease is the leading cause of death in the U.S., accounting for about 600,000 deaths every year, according to the national Centers for Disease Control and Prevention.

About 71 million American adults have elevated levels of LDL or “bad” cholesterol, according to the CDC. A high LDL cholesterol level increases your risk of heart disease, but it does not necessarily mean you should start on a statin, because LDL is just one risk factor out of several that determine your overall risk. Other factors that raise your risk of heart disease include older age, diabetes, having a family history of heart disease, high blood pressure, lack of exercise, whether you are obese, and whether you smoke. Your doctor should ask you about those risk factors and take them into consideration before deciding whether a statin is appropriate for you.

The use of statins has increased sharply in recent years, and they are now among the most widely prescribed medicines in the U.S. Twenty-two percent of Americans 45 years and older take a statin drug, according to the most recent data from the National Health and Nutrition Examination Survey.

As a class, statins and their related combination products generated $16.9 billion in U.S. sales in 2012. One statin, Crestor (rosuvastatin), was the third-top-selling drug in the U.S., accounting for $5.1 billion.

This analysis compares statin drugs with each other and will help you talk with your doctor about your choices and heart-disease risk.

Drugs evaluated in this analysis

Seven statins are now available by prescription in the U.S. They are:

In addition, combination products containing a statin and another lipid-lowering drug are available in the U.S. These drugs are listed below.

The increase in statin prescriptions has prompted controversy over the appropriate use of the drugs. Some doctors and public-health advocates are concerned that too many people are being put on a statin before trying to lower their LDL cholesterol through diet and lifestyle changes.

Some people—such as those with an LDL level greater than 190 mg/dL, those who have heart disease or have previously suffered a heart attack or stroke, and those with diabetes who have a high risk of heart attack or stroke—should start taking a statin as initial therapy.

But for people who don’t fall into those categories and have a 10-year risk of heart attack and stroke that is below 7.5 percent, our medical advisers say that you should not consider a statin, unless you have a genetic condition that causes elevated cholesterol levels or a strong family history of premature heart disease.

If your risk is at or above 7.5 percent but below 10 percent, you could consider a statin, but don’t underestimate the benefit of diet and lifestyle changes. For example, regular aerobic exercise has been shown to lower LDL and raise HDL levels, as well as help you lose weight, which is also associated with a reduction in LDL and a rise in HDL levels. Those changes could lower your risk enough that you are no longer considered a candidate for a statin.

Even after years of attention to this issue, many people remain confused about what constitutes a cholesterol-lowering and heart-healthy diet. For example, many still believe that simply cutting cholesterol-laden eggs out of their diet will do the trick. It won’t if the rest of your diet is high in saturated fats from meat, margarine, butter, and other high-fat dairy products. Following a Mediterranean diet supplemented with olive oil or nuts is the only diet that has been shown in a clinical trial to reduce the risk of heart attacks and strokes. To learn more about a healthy diet, go to Consumer Reports heart health site.

Our recommendations about who should consider a statin drug are based in part on guidelines from the American College of Cardiology and the American Heart Association released in 2013. Those guidelines recommend that your doctor prescribe either a moderate- or high-intensity statin if you fall into one of four groups below. A moderate-intensity statin is expected to reduce LDL cholesterol by 30 percent to 50 percent, while a high-intensity statin would reduce LDL by 50 percent or more. (See table below).

Previous strategies focused on reducing elevated LDL cholesterol levels to very low levels. But the new guidelines look at your overall risk of a heart attack or stroke in the next 10 years as more important than LDL cholesterol levels alone. The guidelines determine your risk based on additional factors, including your age, blood pressure level, whether you smoke, are overweight, or have diabetes or other medical problems.

To calculate your risk of suffering a heart attack or stroke over the next 10 years, the new guidelines use a calculator, found here: http://tools.cardiosource.org/ASCVD-Risk-Estimator/.  It uses your age, blood pressure, gender, levels of total and HDL cholesterol, race, and whether you smoke or have diabetes to generate a risk score. 

This calculator generated controversy when it was released in November 2013. Some experts argued it might overestimate a person's risk, and could put people on a statin who don't actually need one. 

It's good to know that this and other calculators are intended to help estimate you overall cardiovascular risk. The results are simply a guide for you and your doctor to use in deciding if you should take a statin.

The table below lists the four groups of people the new guidelines recommend should receive a statin.

Statin benefit groups and recommendations

* People who are at high risk for side effects from a high-intensity statin should instead take a moderate-intensity statin. This includes people who have multiple and/or serious medical conditions, including impaired kidney or liver function, a history of stroke, muscle disorders or problems with statins, use of medications that could interact with statins, older than 75, and Asian heritage.

The fourth group—those without heart problems or diabetes and a 10-year heart attack/stroke risk higher than 7.5 percent—is controversial because some experts think the 7.5 percent cutoff is too low. Some say it should be as high as 20 percent while others think it should be 10 percent. As noted above, the new guidelines recommend that people in this group consider a statin.

Our medical advisers say that for some people, especially those with a 10-year heart attack/stroke risk less than 10 percent, diet and lifestyle changes should be the first step. That step would include adopting a healthy diet that is low in saturated fats, trans fats, and cholesterol, and making lifestyle changes such as exercising and losing weight if you need to or quitting smoking if you are a smoker. Those changes might reduce your LDL and your heart attack/stroke risk enough that you won’t need to take a statin.

It’s also important to discuss with your doctor your individual risk factors—cholesterol level, age, family history of heart disease, exercise level, and whether you have diabetes, high blood pressure, are overweight or obese, or smoke—to help determine whether a statin makes sense in your situation. In making your decision, our medical advisers recommend that you consider the risk of side effects and also look at how taking a statin will reduce your risk. You might find that a statin will not make much difference in your 10-year risk.

All the statins have been found to reduce levels of LDL cholesterol. And all but two have been found to lower the risk of heart attack and death from heart disease in people with moderate to high risk of heart disease and those who have heart disease or have had a heart attack. But statins differ in their ability to reduce LDL cholesterol. And the evidence is stronger for some statins when it comes to reducing your risk of heart attack or death from heart disease or stroke.

Statins also vary widely in cost. As mentioned, five are now available as generics, and you can save a significant amount of money if you and your doctor choose one of them. This may also help you stay on the drug.

Of course, price is not the only important factor in choosing a statin. As we previously discussed, you and your doctor will want to consider:

• Your risk factors for heart disease, heart attack, and stroke.
• The strength of evidence for each statin.
• The possibility of drug interactions with medicines you are already taking.

If you have had a heart attack

People who have already suffered a heart attack are at very high risk of another (possibly fatal) heart attack and generally benefit from lowering their LDL cholesterol as much as possible.

People who have had a heart attack will probably be prescribed several different kinds of drugs, including a statin, and lifestyle changes will be strongly urged. In studies involving heart patients, atorvastatin has been shown to reduce the risk of second heart attacks and deaths, strokes, and major heart problems. In addition, atorvastatin may be a better option for people who have had a heart attack and need greater LDL reduction.

Strokes

Several statins—atorvastatin, pravastatin, simvastatin, and rosuvastatin (Crestor)—have been proven to prevent strokes. The statins are also widely prescribed for people who have had a stroke or “ministroke,” which doctors call a transient ischemic attack, or TIA. An analysis by the Cochrane Collaboration found that the available evidence indicates overall that statins reduce the risk of fatal and nonfatal strokes by 22 percent.

What about the other statins?

The remaining statins include fluvastatin (Lescol and Lescol XL), pitavastatin (Livalo), and rosuvastatin (Crestor). Fluvastatin and pitavastatin have not been clearly proven to reduce heart attacks, strokes, or deaths. Crestor has been shown to reduce heart attacks and deaths, but there is no reason to take it instead of generic atorvastatin, which is about half the price, depending on dose.

If you fall in one of those groups and you and your doctor have decided a moderate-dose statin is appropriate, we choose the following as Best Buys, based on effectiveness, safety, and cost:

• Generic atorvastatin 10 mg or 20 mg
• Generic lovastatin 40 mg
• Generic pravastatin 40 mg or 80 mg
• Generic simvastatin 20 mg or 40 mg

For people who need a high-dose statin, we selected the following as a Best Buy:

• Generic atorvastatin 40 mg or 80 mg

Warning about high doses

There is one other important issue you should know about as you and your doctor choose a statin. For people who are at high risk of heart attack–for example, if you have diabetes, are a smoker and have elevated LDL levels–studies indicate that the lower your LDL, the lower the risk of heart attack and stroke.

Since higher doses and high intensity statins reduce LDL cholesterol more, the hypothesis has been that they are better and should be used more liberally. And the new ACC/AHA guidelines recommend high-intensity statins if a person does not have any conditions or problems that prohibit their use.

But higher doses and high-intensity statins come with more side effects. Higher doses of all statins have been linked to muscle aches, soreness, tenderness, or weakness. Studies indicate that between one in 20 to one in 10 people who take a statin—regardless of dose—experience these symptoms, and up to 10 percent in some studies have not been able to tolerate an 80 mg dose.

Higher doses have also been linked to an increased risk of a life-threatening form of muscle breakdown called rhabdomyolysis. This can lead to permanent kidney damage, coma, and death.

So even if you fall into a category that should receive a high-intensity statin, we advise caution and careful monitoring for the occurrence of side effects.

What about low-intensity statins?

If you are already taking a low-intensity statin, such as simvastatin 10 mg, pravastatin 10 mg or 20 mg, lovastatin 20 mg, fluvastatin 20 mg or 40 mg, or pitavastatin 1 mg, the new guidelines do not mean that you should necessarily switch to a moderate- or high-intensity statin. This could be a good time to review your risk factors with your doctor to figure out your current risk level and determine whether or not it makes sense to change to a different statin. But if you and your doctor are satisfied that the low-intensity statin you are on is working for you, there’s no reason to switch.

How effective are statins?

Statins reduce the risk of a first heart attack and repeat heart attacks, as well as the risk of death from heart attacks and other forms of heart disease. But some have been studied more extensively than others in terms of both their effectiveness and their safety. And ongoing research continues to define how the statins work and how they differ.

Although all statins reduce LDL cholesterol levels, they have also been evaluated by three other criteria to determine if the drug:

• Reduces nonfatal heart attacks
• Reduces deaths from heart attacks
• Reduces the chance of death due to other causes, including stroke and other forms of heart disease

Reduction of heart attacks

Four statins—atorvastatin (Lipitor and generic), lovastatin (Altoprev, Mevacor, and generic), pravastatin (Pravachol and generic), and simvastatin (Zocor and generic)—have been proven to reduce the risk of heart attack over three to five years of use. And rosuvastatin (Crestor) has been shown to reduce the risk of heart attack over 1.9 years of use. But you should know that the longest studies have only looked at several years of use and no studies have looked at the impact of taking these drugs for 20 to 30 years or longer, the length of time that many people will wind up taking the medicines.

Fluvastatin (Lescol and Lescol XL) and pitavastatin (Livalo) have not been shown to prevent heart attacks and strokes. So we can’t recommend either one.

It’s important to note that although statins reduce the risk of a first or a repeat heart attack, they do not completely eliminate the possibility of these conditions.

In one three-year study that looked at preventing a first heart attack, 5 percent of people who took a placebo had a heart attack compared to 3 percent of those who took a statin. And another recent study found that while people who did not have cardiovascular disease, but did have one or more risk factors (and/or diabetes), benefitted from taking a statin, the reduction in risk was not dramatic. Of those taking statins, 6 percent had a heart attack, coronary event, or stroke versus 8 percent of those taking a placebo.

Reduction of deaths

Four statins—atorvastatin (Lipitor and generic); lovastatin (Altoprev, Mevacor, and generic); pravastatin (Pravachol and generic), and simvastatin (Zocor and generic)—have been found to reduce deaths from heart attacks among patients with a history of heart disease or risk factors for heart disease, such as diabetes and high blood pressure.

In addition, two of the statins–pravastatin and simvastatin–have been found to reduce the overall risk of dying among people considered to be at low risk of heart disease or heart attack. A major study of lovastatin has strongly suggested a similar benefit. Atorvastatin has only been tested—and found to be effective—in reducing deaths in high-risk patients. But here, too, the evidence strongly suggests that it would be effective in reducing deaths among low-risk people as well.

One trial, called JUPITER, showed that rosuvastatin (Crestor) reduced the risk of heart attacks and death in people considered to be at low risk of heart disease or heart attack. While a decrease in heart attack, stroke, and death is good news, the actual reduction was quite small. The rate of these conditions dropped from about 2.8 percent in the placebo group to 1.6 percent in those who took Crestor. In addition, the JUPITER trial was stopped early after 1.9 years. Longer trials are needed to confirm the results.

For people who have had a heart attack

Starting a statin at the time of a heart attack or very soon after can reduce the risk of death substantially—treatment that is fast becoming routine. In an important head-to-head study of people who had a heart attack, a high dose of atorvastatin (Lipitor 80 mg) proved to be more effective in reducing the rate of premature death than a moderate dose of pravastatin (40 mg). In a second recent study, 80 mg of Lipitor reduced nonfatal heart attacks more than a 20 mg dose of simvastatin, but there was no significant difference in the number of deaths among people who took the two different drugs and doses.

How safe are statins?

Overall, statins appear to be quite safe. But they can have two important adverse effects: muscle tissue damage and liver damage. We discuss those safety concerns in more detail below.

Statins also pose a small risk of type 2 diabetes. The FDA added that risk to the labeling of all statins in 2012 after reviewing several studies that had found an increased risk of elevated blood sugar levels and diabetes in people who took the medications. For example, an analysis of 13 studies published in the journal Lancet in February 2010 found a 9 percent increased risk of diabetes in people who used statins. Or looked at another way, there would be one extra case of diabetes for every 255 people who took a statin for four years.

The FDA says statins can also cause memory loss, forgetfulness, and confusion. The FDA, which added this risk to the labeling of statins in February 2012, said studies and reports it has received indicate there have been rare cases of people who developed memory loss or impairment after taking the medications. Some people developed memory problems one day after taking a statin while others did not experience any problems until they had been taking a statin for years. The problems did not appear to be linked to higher doses of statins. The memory problems, which occurred in people over the age of 50, went away when the statin was stopped. In addition, as we previously noted, the long-term effects of taking statins for decades has not been assessed. So while these drugs appear to be relatively safe over several years of use, it’s uncertain if taking the medicines for 20 to 30 years or longer raises any unique concerns.

Because of the risk for birth defects, women who are pregnant or trying to become pregnant should not take any statin drug. Women who are breast feeding should not take a statin as well.

Muscle tissue damage

As we’ve previously noted, statins can cause muscle aches, soreness, tenderness, or weakness in up to 5 to 10 percent of people taking them. This includes people taking lower doses, although low doses (10 mg and 20 mg) are much less likely to cause problems.

The symptoms of muscle problems include unexplained muscle weakness or pain, feeling very tired even though you’ve slept well, nausea and vomiting, stomach pain, and brown- or dark-colored urine. Consult your doctor immediately if you begin to have any of those symptoms. These symptoms usually go away within days or weeks after you stop taking the drug. But they could be signs of a rare, life-threatening form of muscle breakdown called rhabdomyolysis. This can lead to permanent kidney damage and coma. One statin, cerivastatin (Baycol), was withdrawn from the U.S. market in 2001 because it caused several deaths due to rhabdomyolysis.

Larger doses of statins raise the risk of muscle aches, weakening, and rhabdomyolysis, as discussed below in Differences among statins section. Taking a statin in combination with certain other drugs (gemfibrozil, niacin, and verapamil; check with your doctors for a list of others) can also significantly increase the risk of muscle damage and rhabdomyolysis. For the same reason, several additional drugs should not be taken with simvastatin, including:

• some antibiotics (erythromycin, clarithromycin, telithromycin)
• some antifungal medications (itraconazole, ketoconazole, posaconazole)
• cyclosporine, an immunosuppressant
• danazol (used to treat endometriosis)
• HIV protease inhibitors
• nefazodone, an antidepressant

Doses of simvastatin greater than 20 mg per day increase the risk of rhabdomyolysis when used in combination with amiodarone, a drug for treating an irregular heartbeat, amlodipine (used to treat high blood pressure), and ranolazine (used to treat angina).

The cholesterol-lowering drug ezetimibe (Zetia) has been associated with muscle aches and rhabdomyolysis when used on its own and in combination with statins.

Other factors that increase the risk of rhabdomyolysis include alcoholism, low phosphate levels, extreme exercise (such as running a marathon), and the use of illegal drugs, such as cocaine, heroin, and PCP.

Liver problems

Liver problems while taking a statin are uncommon, and when it occurs it’s usually mild. Nevertheless, the FDA advises patients prescribed a statin to have liver function tests before starting treatment. Contact your doctor immediately if you develop signs of liver problems, which include unusual fatigue or weakness, loss of appetite, dark-colored urine, or your skin or whites of your eyes begin to turn yellow.

Differences among statins

Overall, statins at low doses do not differ with respect to the risks of these adverse effects. Generally, people taking 10 mg or 20 mg of any of the statins are at very low risk of muscle or liver problems. But studies in recent years have raised concerns about muscle damage associated with high doses of some of the statins. The largest study of the safety of a statin followed 8,245 people who took generic lovastatin in doses of 20 mg, 40 mg, or 80 mg for four years. The incidence of muscle and liver problems increased with increasing doses.

The available evidence indicates the highest dose of simvastatin—80 mg—poses an increased risk of muscle problems and rhabdomyolysis, so the FDA recommends that the 80 mg tablet not be used except in people who have already been taking it without problems for a year or longer.

Most experts think–and the evidence so far strongly suggests–that all the statins have the potential to cause muscle problems at high doses. But until definitive studies are done, it is not clear whether some statins now on the market may pose more of a risk than others.

Finally, studies have found that grapefruit juice can enhance the absorption of statin drugs. While no studies have found any ill effects from this, in theory it could increase the potential for muscle and liver problems, or other minor side effects. If you are taking a statin and enjoy grapefruit juice, talk with your doctor.

Age, race, and sex differences

Women, people over 65, and members of various ethnic groups have been under-represented in the major studies of statins. But one review of the studies suggests that the drugs are equally effective and safe in men, women, and people over 65.

But the benefits of statins are uncertain in women who have very marginally elevated LDL and do not already have heart disease or other risk factors. We advise women who fall into this category to discuss this issue with their doctor. In addition to your LDL level, the discussion should also focus on your overall heart disease risk, based on whether you have other risk factors (55 or older, diabetes, family history of heart disease, high blood pressure, lack of exercise, overweight or obese, smoker). Bear in mind that at any particular age and LDL level, women generally have a much lower risk of heart disease than men. So if your risk is low and your doctor suggests a statin, you should ask whether it’s really necessary at this point in your life.

And as we have previously stated, women who are pregnant, trying to become pregnant, or breastfeeding should not take any statin drug.

If you are of Asian heritage (Filipino, Chinese, Japanese, Korean, Vietnamese, or Asian-Indian), you should know that the labeling for rosuvastatin (Crestor) notes that studies have found levels of the drug that were twice as high in Asian people compared with Caucasians. The labeling advises that the dosage of the drug be adjusted accordingly for Asian people. Some advise that people of Asian heritage begin initially with a 5 mg dose.

All of our Best Buys—atorvastatin, lovastatin, pravastatin and simvastatin—have been shown to reduce the risk of heart attack and deaths from heart attacks, and they are all available as inexpensive generics. You could save more than $100 per month if you pay out-of-pocket and you choose a generic instead of a brand name statin.

If you and your doctor have decided a moderate-intensity statin is appropriate, we choose the following as Best Buys, based on effectiveness, safety, and cost

• Generic atorvastatin 10 mg or 20 mg

• Generic lovastatin 40 mg

• Generic pravastatin 40 mg 

• Generic simvastatin 20 mg or 40 mg

For people who need a high-intensity statin, we selected the following as a Best Buy

■ Generic atorvastatin 40 mg or 80 mg

If you currently take one of the high-intensity statins Crestor or Lipitor, but you don’t meet the ACC/AHA’s criteria for such a potent statin, a switch to one of our moderate-intensity Best Buy statins could save you thousands of dollars over the many years you may have to take a statin.

For example, for people with health insurance plans that require a co-pay of $25 for a brand-name drug, such as Crestor, vs. a $7 co-pay for generic simvastatin, that represents an $18 difference, which amounts to a savings of $216 per year, or $1,080 over 5 years. For people who are without health insurance or adequate drug coverage, the savings would be much more. Talk to your doctor about whether switching makes sense in your case.

People with special considerations

The table below presents statin recommendations for people who take medications for specific medical conditions. If you have one of these conditions, you should discuss it with your doctor so he or she can help you determine which statin is the safest and most effective for your situation.

In particular, medicines for HIV and AIDS and those used to prevent the rejection of transplanted organs can increase the toxicity of statins. Statins can also increase the effect of blood thinners, such as warfarin (Coumadin and generic), and can interact with many other medications, including those used to control blood pressure.

This is not a comprehensive list. Your doctor may advise you to take a particular statin if you have other conditions or chronic diseases. It’s wise to tell your doctor about any prescription or nonprescription medicine and dietary supplements you are taking, as well as any medical conditions you have. And you should always carefully read the labeling or package insert that comes with your medicine. It contains essential information about how to take the medication and side effects and drug interactions you should be aware of.

Statin Choices for People With Special Considerations

1. Because they have been shown effective in this population of patients.

2. Protease inhibitors include indinivir, nelfinavir, ritonavir, saquinavir, amprenavir, and the combination drug lopinavir/ritonavir.

Ezetimibe (Zetia) has racked up more than $1.1 billion in sales, but our medical advisers recommend skipping it and combination medications that contain it, such as Liptruzet and Vytorin (See box below).

Simcor, an extended-release combination of simvastatin and niacin, has been associated with an increase in adverse events that cause people to stop taking the drug compared with those who took simvastatin alone.

There is another combination tablet available that contains a statin and a drug used for treating high blood pressure for people who have both conditions.

The brand name of that drug, which we do not evaluate in this report, is Caduet. It is a combination of the calcium channel blocker amlodipine (Norvasc and generic) and atorvastatin (Lipitor and generic).

Skip Liptruzet, Vytorin, Zetia

Since the new guidelines focus on preventing heart attacks and strokes—not LDL lowering—there is no longer any reason to take Liptruzet, Vytorin, or Zetia.

Zetia (ezetimibe) is a different type of cholesterol-lowering medication than a statin. It decreases cholesterol absorption in the intestines. But it has not been shown to reduce heart attacks or strokes.

Vytorin combines simvastatin with ezetimibe in a single pill. Liptruzet is a combination of atorvastatin and ezetimibe. But there is no evidence that either Liptruzet or Vytorin works better than the statin alone to prevent heart attacks or strokes.

Two studies cast doubt on the benefits of Vytorin. The first was a two-year study that showed Vytorin was no better than simvastatin alone in reducing plaque buildup in arteries. The second was a five-year study that showed Vytorin did not reduce heart attacks or strokes compared to a placebo.

Merck, the manufacturer of Liptruzet, says the combo medication has not been proven to reduce the risk of heart attacks or strokes more than atorvastatin alone.

Our evaluation is based in part on an independent scientific review of the studies and research literature on statin drugs conducted by a team of physicians and researchers at the Pacific Northwest Evidence-Based Practice Center. This analysis reviewed 347 studies, including 225 clinical trials, 80 observational studies, and 21 systematic reviews. The analysis also included studies conducted by the drugs’ manufacturers. This effort was conducted as part of the Drug Effectiveness Review Project, or DERP. DERP is a first-of-its-kind, multistate initiative to evaluate the comparative effectiveness and safety of hundreds of prescription drugs.

This update of our previous statin report also relied on a recent review of combination therapies conducted for the Agency for Healthcare and Research Effective Healthcare Program. It is available here.

The monthly costs we cite were obtained from a health-care information company that tracks the sales of prescription drugs in the U.S. Prices for a drug can vary quite widely. All the prices in this report are national averages based on sales in retail outlets. They reflect the cash price paid for a month’s supply of each drug in October 2013.

Consumer Reports selected the Best Buy Drugs using the following criteria. The drug had to:

• Be in the top tier of effectiveness among the seven statins

• Have a safety record equal to or better than other statins

• Have an average price for a 30-day supply that is lower than the most costly statin meeting the first two criteria

The Consumers Reports Best Buy Drugs methodology is described in more detail in the Methods section at www.CRBestBuyDrugs.org.

1. Anonymous, MRC/BHF Heart Protection Study of cholesterol lowering therapy and of antioxidant vitamin supplementation in a wide range of patients at increased risk of coronary heart disease, death, early safety, and efficacy experience. European Heart Journal, 1999. 20: p.725-41.

2. Anonymous, Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. New England Journal of Medicine, 1998. 339: p.1349-57.

3. Arnett, D.K., et al. Twenty year trends in serum cholesterol, hypercholesterolemia and cholesterol medication use, 1980-2002, Circulation (December 20, 2005), Vol. 112.

4. Bradford, R.H., et al. Expanded clinical evaluation of lovastatin (EXCEL) study design and patient characteristics of a double blind, placebo controlled study in patients with moderate hypercholesterolemia. American Journal of Cardiology, 1990. 66: p.44B-55B.

5. Bradford, R.H., et al. Expanded Clinical Evaluation of Lovastatin (EXCEL) study results. I. Efficacy in modifying plasma lipoproteins and adverse event profile in 8,245 patients with moderate hypercholesterolemia [see comments]. Archives of Internal Medicine, 1991. 151: p.43-9.

6. Bradford, R.H., et al. Expanded clinical evaluation of lovastatin (EXCEL) study results III . Efficacy in modifying lipoproteins and implications for managing patients with moderate hypercholesterolemia. American Journal of Medicine, 1991. 91:p.18S-24S.

7. Bradford, R.H., et al. Efficacy and tolerability of lovastatin in 3,390 women with moderate hypercholesterolemia. Annals of Internal Medicine, 1993. 118: p.850-5.

8. Bradford, R.H., et al. Expanded Clinical Evaluation of Lovastatin (EXCEL) study results, two year efficacy and safety follow up. American Journal of Cardiology, 1994. 74: p.667-73.

9. Cannon, C.P., et al. Intensive and moderate lipid lowering with statins after acute coronary syndromes. New England Journal of Medicine, 2004. 350(15): p.1495-1504.

10. Cannon, C.P., The IDEAL cholesterol: lower is better, JAMA (Nov. 16, 2005), 294:2492-2494. Carrol, M.D., et al. Trends in serum lipids and lipoproteins of adults, 1960-2002, JAMA (Oct. 12, 2005), Vol 294: 1773-1781.

11. Davidson, M.H., et al. Lipid-altering efficacy and safety of simvastatin 80mg/day: worldwide long-term experience in patients with hypercholesterolemia. Nutrition Metabolism & Cardiovascular Diseases, 2000. 10(5): p.253-62.

12. de Lemos, J.A., et al. Early Intensive vs. a Delayed Conservative Simvastatin Strategy in Patients With Acute Coronary Syndromes: Phase Z of the A to Z Trial. JAMA, 2004.

13. Downs, J.R., et al. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels results of AFCAPS/ TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention Study. JAMA, 1998. 279: p.1615-22.

14. “Drugs for Lipids,” The Medical Letter (February 2008), Issue 66.

15. Fox. R., et al. Ezetimibe and statin-associated myopathy, Ann. Int. Med (April 2004), Vol. 140: 671-672.

16. Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, et al; National Heart, Lung, and Blood Institute. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227-39.

17. Heart Protection Study Collaborative Group, MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet, 2002. 360: p. 7-22.

18. Kent, D.M. Stroke–an equal opportunity for the initiation of statin therapy. New England Journal of Medicine (Aug. 10, 2006); 355: 613-615.

19. LaRosa, J.C., J. He, and S. Vupputuri. Effect of statins on risk of coronary disease: a metaanalysis of randomized controlled trials. JAMA, 1999. 282(24): p.2340-6.

20. Paaladinesh, T., et al. Primary prevention of cardiovascular diseases with statin therapy; a metaanalysis of randomized controlled clinical trials, Archives of Internal Medicine (Nov. 27, 2006); 166:2307-2313.

21. Pedersen, T.R., et al. High-dose atorvastatin vs. usual dose simvastatin for secondary prevention after myocardial infarction–The IDEAL study. JAMA (Nov. 15, 2005), 294:2437-2445.

22. Pedersen, T.R., Randomised trial of cholesterol lowering in 4,444 patients with coronary heart disease The Scandinavian Simvastatin Survival Study (4S). Lancet, 1994. 344: p.1383-1389.

23. Sacks, F.M., et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators. New England Journal of Medicine, 1996. 335(14): p. 001-9.

24. Serruys, P., et al. The Lescol (R) Intervention Prevention Study (LI PS): A double-blind, placebo-controlled, randomized trial of the long-term effects of fluvastatin after successful transcatheter therapy in patients with coronary heart disease. International Journal of Cardiovascular Interventions., 2001. 4(4): p.165-172.

25. Serruys, P.W., et al. Fluvastatin for Prevention of Cardiac Events Following Successful First Percutaneous Coronary Intervention: A Randomized Controlled Trial. JAMA, 2002. 287:p.3215-3222.

26. Sever, P.S., et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm (ASCOT-LLA): a multicentre randomized controlled trial. [comment]. Lancet, 2003. 361(9364): p. 1149-58.

27. Sever, P.S., et al. Rationale, design, methods, and baseline demography of participants of the Anglo-Scandinavian Cardiac Outcomes Trial. ASCOT investigators. Journal of Hypertension, 2001. 19(6): p.1139-47.

28. Sever, P.S., et al. Anglo-Scandinavian Cardiac Outcomes Trial: a brief history, rationale, and outline protocol. Journal of Human Hypertension, 2001.15 (Suppl 1): p.S11-2.

29. Sharma M, Ansari MT, Abou-setta AM, Soares-Weiser K, Ooi TC, Sears M, et al., Systematic Review: Comparative Effectiveness and Harms of Combinations of Lipid-Modifying Agents and High-Dose Statin Monotherapy. Ann. Int. Med. 2009;151.

30. Shepherd, J., et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. New England Journal of Medicine, 1995. 333(20): p.1301-7.

31. Taylor, F, Huffman MD, Macedo AF, Moore THM, Burke M, Davey Smith G, Ward K, Ebrahim S. Statins for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD004816. DOI: 10.1002/14651858.CD004816.pub5.

32. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators, high-dose atorvastatin after stroke or transient ischemic attack. New England Journal of Medicine (Aug. 10, 2006); 355: 549-59.

These materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multistate settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).

Consumer Reports has no relationship with any advertisers or sponsors on this website. Copyright © 2006-2014 Consumers Union of U.S.