Which statin is best?

17. February 2008 William Davis (6)
The statin drugs can indeed play a role in a program of coronary plaque control and regression.

However, thanks to the overwhelming marketing (and lobbying and legislative) clout of the drug manufacturing industry, they play an undeserved, oversized role. I get reminded of this whenever I'm pressed to answer the question: "Which statin drug is best?"

In trying to answer this question, we encounter several difficulties:

1) The data nearly all use statins drugs by themselves, as so-called monotherapy. Other than the standard diet--you know, the American Heart Association diet, the one that causes heart disease--it is a statin drug alone that has been studied in the dozens of major trials "validating" statin drug use. The repeated failure of statin drugs to eliminate heart disease and associated events like heart attack keeps being answered by the "lower is better" argument, i.e., if 70% of heart attacks destined to occur still take place, then reduce LDL even further. This is an absurd argument that inevitably encounters a wall of limited effects.

2) The great bulk of clinical data examining both the incidence of cardiovascular events as well as plaque progression or regression have all been sponsored by the drug's manufacturer. It has been well-documnted that, when a drug manufacturer sponsors a trial, the outcome is highly likely to be in favor of that drug. Imagine Ford sponsors a $30 million study to prove that their cars are more reliable and safer. What is the likelihood that the outcome will be in favor of the competition? Very unlikely. Such is human nature.

If we were to accept the clinical trial data at face value and ignore the above issues, then I would come to the conclusion that we should be using Crestor at a dose of 40 mg per day, since that was the regimen used in the ASTEROID Trial that achieved modest reversal of coronary atherosclerotic plaque by intravascular ultrasound.

But I do not advocate such an ASTEROID-like approach for several reasons:

1) In my experience, nobody can tolerate 40 mg of Crestor for more than few weeks, a few months at most. Show me someone who can survive and tolerate Crestor 40 mg per day and I'll show you somebody who survived a 40 foot fall off his roof--sure, it happens, but it's a fluke.

2) The notion that only one drug is necessary to regress this disease is, in my view, absurd. It ignores issues like hypertension, metabolic syndrome, inflammatory phenomena, lipoprotein(a), post-prandial (after-eating) phenomena, LDL particle size, triglycerides, etc. You mean that Crestor 40 mg per day, or other high-intensity statin monotherapy should be enough to overcome all of these patterns and provide maximal potential for coronary plaque reversal? No way.

3) Plaque reversal can occur without a statin agent. While statin drugs may provide some advantage in the reduction of LDL, much of the benefit ends there. All of the other dozens of causes of coronary atherosclerotic plaque need to be addressed.

So which statin is best? This question is evidence of the brainwashing that has seized the public and my colleagues. The question is not which statin is best. The question should be: What steps do I take to maximize my chances of reversing coronary atherosclerotic plaque?

The answer may or may not involve a statin drug, regardless of the subtle differences among them.


Copyright 2008 William Davis, MD
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Comments (6) -

  • Cindy Moore

    2/17/2008 11:25:00 PM |

    How about "What steps do I take to maximize my chances of preventing coronary atherosclerotic plaque?"

  • Anonymous

    2/18/2008 5:11:00 AM |

    Have you ever had your patients get a big rise in HDL from any statin, assuming they have an adequate vitamin D level?

    I ask, as my cardiologist recommended a statin initially (Crestor, then Lipitor, then Zetia), for my HDL, before I suggested Niacin instead -- which is what I am taking now.. I just  found it bizarre to recommend Crestor first, so was wondering if perhaps a statin could raise HDL in some individuals by a noticeable amount?

    Although the data states it typically (at best) only raises it like 10% or so. And my nurse said for people with normal-low LDL, quite often a statin can lower HDL too. And I have normal LDL, no major risk factors, except a low HDL level.

    My doctor simply wrong suggesting a statin? It wouldn't be the first time...

  • Anonymous

    2/20/2008 1:54:00 PM |

    I just quit my long term lipitor and my cognitive abilities seem better, my balance seems better and my legs don't ache. I am doing TYP.

    CHICKADEE

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    11/3/2010 3:15:54 PM |

    1) In my experience, nobody can tolerate 40 mg of Crestor for more than few weeks, a few months at most. Show me someone who can survive and tolerate Crestor 40 mg per day and I'll show you somebody who survived a 40 foot fall off his roof--sure, it happens, but it's a fluke.

  • Tessica

    7/10/2011 6:44:57 AM |

    One or two to reemmber, that is.

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