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RADIO SCIENCE UNIT
CHECK UP
Programme 6. - Statins
RADIO 4
THURSDAY 01/08/05 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
SIMON DAVIES
PRODUCER:
ERIKA WRIGHT
MYERS
Well we often mention different drug treatments in Check Up but we don't usually spend the whole programme on one particular medicine. This week though we're taking your calls on a drug that is being taken by over a million of us and that number is set to rise. Cholesterol lowering drug statins have been tried and tested for 20 years and are known to reduce coronary heart disease and stroke by a third. As well as being effective they're usually well tolerated by patients, which is just as well because once you start on them you can expect to stay on them for life. So are they for everyone and are they the whole story? If we do take them does it mean we don't need to worry about other known risk factors for cardiovascular disease such as smoking, poor diet and lack of exercise? Call us now: 08700 100 444 or you can e-mail checkup@bbc.co.uk with your questions for Dr Simon Davies, he's a consultant cardiologist at London's Royal Brompton Hospital.
We have our very first caller on the line, she's Sandra, she's calling from Swindon. Hello Sandra, with your question please.
SANDRA
Oh hello, hello to you both. Cholesterol levels - since I'm a diabetic I realise that I really have to keep a very strict check on these and I'm just wondering what are the acceptable levels, has the medical profession revisited and revised its view over time as to what is sort of acceptable?
DAVIES
Hello Sandra.
MYERS
Well I think that's a very, very good question for Simon to start with.
DAVIES
It is. I think an oversimplified answer would be a cholesterol of 5. It's a quite good rule of thumb. I think an ideal cholesterol would be less 5 and if it's over 5 you'd start to think about improving diet and perhaps eventually drugs. But you've already got us into the point that the number isn't everything and for people with diabetes the lower the better, maybe 4.
MYERS
Have you any idea of your cholesterol level Sandra?
SANDRA
Yes it was 6 and we've got it down to 5. And that's with the help of statins.
DAVIES
Well that's pretty good but as you said the medical profession have revised their opinions and there's a tide of opinion that keeps shifting the goalposts and I think ...
SANDRA
Down.
DAVIES
The lower the better and I think that in 2005 for someone with diabetes it would be nice to have a cholesterol that bit lower, nearer 4.
SANDRA
Right.
MYERS
And how are you getting on with your statins though, it's lowering your cholesterol level and you're happy on that?
SANDRA
Yes, I actually can't - I'm unaware of any side effects at all and I'm perfectly happy to take them. And ...
MYERS
Well one satisfied customer.
DAVIES
Fantastic.
MYERS
It's doing the trick. I mean it's interesting to know Simon, I think you said very briefly, how statins - I mean they have been hailed as something of a breakthrough class of drug, very valuable - is there a simple way of our understanding how they do this - lower this important figure for blood cholesterol?
DAVIES
Yeah, they block a chemical in the liver that makes cholesterol. So it's fairly simple actually. They act on a key stage, they don't act immediately and if you start taking the tablets once a day it's actually a few weeks before the cholesterol gradually comes down to its new level. But they turn off the tap at source.
MYERS
Okay, very good, thank you very much. We'll go to Michael Day who's got a question about cholesterol. Doesn't want to take statins, do you - have you been advised to take statins Michael, that's the first thing?
DAY
I have but I'm reluctant to take them, although my cholesterol is going up.
MYERS
What is it, do you know?
DAY
It's 7.79 at the moment and I had a gall bladder removal in May and they thought that would reduce my cholesterol but in fact it hasn't.
MYERS
And 7.79 is obviously rather higher than Simon Davies has just said as being a sort of threshold or acceptable level of around 5.
DAY
But I feel perfectly fit.
DAVIES
Ah. Did they take your gall bladder out because it contained a stone?
DAY
Yes it had a large stone.
DAVIES
Yeah, I imagine that stone was made of solid cholesterol because your blood cholesterol of 7.8, 7.9 is really very, very high indeed. My worry is that you're feeling well but I wonder whether the cholesterol is starting to deposit in the arteries and harden them and it would be nice to nip this in the bud before you actually had something terrible like a heart attack or a stroke.
DAY
Right.
MYERS
Is there any other way of nipping it in the bud because I guess there are other factors that come into play here, for example weight and other lifestyle factors?
DAVIES
You're absolutely right Barbara and I'm sure Michael that you've been talked about and thought about all the lifestyle changes ...
DAY
I'm a reasonable weight but I do sell cheese for a living.
DAVIES
That is difficult.
MYERS
You sell cheese for a living which means I guess you taste cheese and that is a high fat food at the best of times, isn't it.
DAVIES
I guess it is. Well you certainly don't have to give up the cheese but it would be good if your weight was at the right level for your height and I guess most of us in this country are likely to be a little bit over the ideal.
MYERS
Why are you so resistant Michael to going on to statins if that's been suggested to you?
DAY
Because the boredom threshold and the worry actually of taking a pill everyday for the rest of your life, if I had a bad heart I might take [indistinct word] or something but ...
MYERS
Ah but if you don't perhaps don't take them you might have a bad heart which is to turn the thing round. What do you think about that - I mean is this something you would have to take for life and what about that worry of taking something?
DAVIES
Yeah, I think Michael what you've said is what a lot of patients say. I think it makes us feel differently about ourselves if you've now become someone who has to take tablets on a regular basis. So I can completely sense the resistance. To have a tablet at the bedside and to take it last thing at night, because that's when statins are best taken, they work best if you take them at night rather than in the morning, to keep a packet of these statins next to your toothbrush probably wouldn't be the end of the world. And the problem in the UK is we just have so much heart and stroke disease and if taking these tablets brought it from 7.9 down to somewhere nearer 5 you could more than halve your risk of heart attack or stroke.
MYERS
Oh well that's quite dramatic isn't it.
DAVIES
I mean that's the carrot for taking them, even though in an ideal world you might do it entirely through diet and exercise. If you're as high as 7.8, 7.9 it's unlikely you'll get it as low as I would want it by the lifestyle measures. And if the tablet prevented that kind of a disaster, although you feel well now, it would seem to be worth the effort.
MYERS
So does that act as a bit of an incentive hearing that - you could cut your risk of a heart attack by half?
DAY
I think it does.
MYERS
Okay.
DAY
I'll accept your advice.
MYERS
Okay, so back to the doctor and see what he has to say or she. Let's go to another caller though if we may, thanks for that Michael, we'll go to Paul Hobbs who's in Surrey, who's calling on behalf of his wife who has high cholesterol but doesn't want to go on statins, perhaps like Michael in that case. Is that the case Paul?
HOBBS
Yes it is. Statins have not always had a good report and my wife is obviously concerned about going on something for life which has had press of bad effects. But the situation or question I have for you is that her last reading was 6.4 but - I'm not sure if it was the LDL or HDL was 2.3 and the ratio was 4.5.
MYERS
Alright, lots of figures there, let's get Simon Davies to unpick some of those for us. So we're talking now not just about the overall cholesterol level of six point something but actually sort of drilling down a little bit looking at good and bad cholesterol. Can you can help us with that first and then we'll try and answer Paul's question directly?
DAVIES
Sure. Well the cholesterol in the circulation is all measured in one lump, which is I guess the 6.4, but in fact there are two main forms - the good and the bad. The LDL, the low density lipoproteins are the bad ones, they fur up the arteries and do the damage. The HDL is actually good, the high density lipoprotein is good, it's the cholesterol that's a bit like a road sweeper going around tidying up the streets, it's taking the cholesterol out of the artery and bringing it back to the liver. So it's going the other way. So you're right, it's not just knowing that it's 6.4, it's knowing the balance of the HDL and LDL. But on a ready reckoner of the numbers you've given me I think your wife's cholesterol is too high. It's not just that the total is quite a way north of the ideal of 5 that we just mentioned but I think she has a fair amount of the bad LDL in there.
MYERS
So in and of itself that might be a good reason to have medication. Are there any other risk factors do you think Paul that perhaps would tip you or her over into accepting that medication was the answer?
HOBBS
Can I just ask, what is the importance of the ratio which is 4.5?
DAVIES
It's ...
HOBBS
One doctor's saying your ratio is very good you don't have to have statins, another one is saying the overall level of 6.4 is high you do need to go on statins.
DAVIES
Yeah, the ratio is just one way of looking at the balance of HDL and LDL and if the ratio is less than 5 that is a help but I still think that 6.4 is too high.
HOBBS
Fine, thank you very much. I'll ask you the other point. My wife does have a heart problem and history, high blood pressure, she's currently taking Atenolol for that and her father died of a heart attack when he was 55, mother had angina - so there is a history and we just want to make sure we're doing the right thing.
DAVIES
Well all the additional things you've told me - you know the fact there's a family history of disease, the fact that she also has high blood pressure has kind of kicked this into touch. I think the case then for having a statin is a really strong one. Remember we said that for all of us the ideal is to have a cholesterol of 5 or less but for somebody with these other factors even lower would be better and that just puts 6.4 at a level where the tablets would definitely, definitely have great benefits that I would have thought would outweigh any potential for side effects.
MYERS
But of course the point worth reiterating - we're not condemning someone to medication, I mean we're saying that this is actually going to really increase their risk of a long and healthy life without the risk of - or certainly a lower risk than otherwise - of a heart attack or a stroke.
DAVIES
Yeah, I mean it's longevity really. And it doesn't - a few people get aches and pains and a few side effects but they're uncommon and the fact is the amount of life to come free of a heart attack or a disabling stroke is a really positive thing.
MYERS
Paul, thank you for that, I hope the message is clear enough there. Let's take an e-mail though which links into what we've just been saying and this is from Chris who, he says, has a family with a history of raised cholesterol levels. His, he says, is slightly high, he says it's 6.5 and he's wondering if statins is the right answer or whether a low fat diet is a better answer.
DAVIES
Yeah. I think we'd always want to start the treatment with non-drug treatment, in other words lifestyle. So there's never any harm and there's possibly a lot of benefit in trying diet, exercise and above all losing weight as first measures. But if after three to six months of making a real effort with those things the cholesterol's still high then you would consider a statin. So I think lifestyle measures first, it's not necessarily that one is better than the other.
MYERS
And is it quite possible that you could lose weight, perhaps get down to a target weight and still have a high cholesterol?
DAVIES
Yeah. I mean there's no doubt that if you lose weight your cholesterol will come down. But in some people it'll come down so much that the statin is no longer needed and in other people it only comes down a little bit and they're often the people with a family history - so it's the genetic elements. So losing the weight always helps a bit but you're right and the people with a family history it may not be enough.
MYERS
Let's go to another call now and we've got Billie Marchmont, who's in Powys, with I think side effects, you said there aren't so many side effects but I think Billie you've got some, have you?
MARCHMONT
I have indeed.
DAVIES
I'm sorry to hear that.
MYERS
Better tell us about it.
MARCHMONT
Well I've been on statins now for many years and certainly they have reduced my blood cholesterol because it was 9.9 when I went on them. The current reading is 5.8. But just three weeks ago I had very, very severe muscle pain in my thighs and the back of my thighs and not quite so bad in the calf and I couldn't work out what the hell was happening to me basically because I do read all the contra-indications on all the literature of any medication that I take. But of course being on it for so many years you forget. And they sent bloods through to the local path lab and instead of the normal reading of what 150, although I understand GPs are not really worried if it doubles or trebles, mine was 11,000.
DAVIES
Gosh.
MARCHMONT
They took me off Simvastatin immediately, I had bloods done the following day and it had dropped to 9,000. My husband is a Reiki practitioner and he fortunately, once I had all the bloods done because I didn't want to cloud anything, got me out of pain. but I'm now extremely tottery and very weak in the legs. It got to the stage where I couldn't lift my foot even two inches off the ground, I couldn't get upstairs, I couldn't get on and off the loo, let's face it I couldn't even put my own knickers on and get them off. This pain was extremely severe.
DAVIES
Well you're right this is a known side effect of statins but something as bad as this is very, very rare indeed. I think 1, 2, 3, 4% of people can have minor aches and pains and no serious ill effects.
MARCHMONT
I've had nothing up till now at all.
DAVIES
Well less than one person in a thousand, quite literally, less than one person in a thousand the statins cause a serious inflammation in the muscles. Now what's particularly unusual in your case is that you took them for such a long time without a problem and it makes me think that something else has changed because this isn't the normal pattern. Normally if people have this reaction it happens in the first few weeks or months. One thing that's known to do this is if the thyroid gland becomes underactive and I know this is a long shot but I just wonder whether ...
MARCHMONT
They've checked it.
DAVIES
Have they? And was it normal.
MARCHMONT
Yes everything is normal.
DAVIES
Well then the other thing it makes me ...
MARCHMONT
But it is a new - it is a new drug, it's one I have not been on before.
DAVIES
Oh you've changed?
MARCHMONT
Well it changes every time you go doesn't it really?
DAVIES
Yeah, no ...
MARCHMONT
And then this one wasn't an APS one.
DAVIES
Right, I just wondered if there was something funny going on there. But I'm sorry to hear you've had such a bad problem. Minor aches and pains - 2, 3, 4% - this kind of severe inflammation in the muscles, it does always get better when you stop but thank goodness it is rare - less than one in a thousand.
MYERS
Okay thank you for that. I mean it raises a couple of questions. One is that they're clearly, although it's a class of drugs known of statins, there are different types within it, so is that a matter sometimes of trying a different one if what you've been put on may have some side effects?
DAVIES
I think that firstly some are a little bit stronger and some are a little bit milder, so it's always important to have some follow-up when you've gone on the statin the cholesterol should be measured about a month later and the dose increased or the drug changed if the cholesterol hasn't come down enough. But equally if you start to have aches and pains or another side effect it is worth asking your GP to change from one to another.
MYERS
Is dizziness a side effect? Someone's raised that on an e-mail.
DAVIES
Not that I've ever come across and as you can imagine as a cardiologist the vast majority of my patients are on statins for the heart in one way or another. I haven't really come across dizziness - aches and pains, very occasionally slight constipation or diarrhoea. I guess anything is possible but I don't think dizziness is a common one.
MYERS
And the next question really is whether there are different drugs altogether that are not statins that might have the same effect. Actually we've got a call from Una in Cheshire, I think that relates to your question doesn't it Una?
UNA
It does yes.
MYERS
What's your question exactly then?
UNA
Well I'm a diabetic, I'm 80 years old and I have neuropathy through the diabetes. I'm on Atorvastatin statin - 10 milligram - but they give me muscle aches and tummy upsets, mainly wind in the tummy and a pharmacist suggested I might be able to go on fibrates. Now would that have the same effect as the statin?
DAVIES
The short answer yes, the fibrates are a good class of drugs for bringing down the cholesterol. They don't quite bring it down as much as the statins, the statins are more effective. But the fibrates are useful in people who don't - who can't tolerate the statins, people like you who've been unlucky to have the muscle side effect and the little bit of tummy upset. But they also do something else - they tend to lower another fatty substance in the blood, something called triglycerides which often is high in diabetics. So it may not be a bad thing at all to take the fibrates.
UNA
My cholesterol at the moment is 5.3.
DAVIES
That isn't bad. Forgive me mentioning the fact that you're 80 but cholesterol in all of us tends to go up a little bit with age. So whilst the ideal would be to be under 5 and perhaps with diabetes even to be a bit lower, 5.3 isn't too bad.
MYERS
But the diabetes is a sort of in itself another risk factor is it?
DAVIES
It is. And the difficult thing here is not only does having diabetes push your cholesterol up but the sugar in the blood makes the cholesterol more sticky and that's why - is the reason why in a diabetic we'd be particularly keen to use some drug, whatever, to get the cholesterol down below 5.
MYERS
Are there any other conditions, if you have some other disease, that mean that you can't take statins, even if you might have a high blood cholesterol?
DAVIES
I think there are, I think the most important of those is a hormonal condition which is particularly common in women having an underactive thyroid. And this is a little bit of a catch because having an underactive thyroid leads to a high cholesterol but at the same time having an underactive thyroid makes your muscles more sensitive and makes it much more likely that you'll get the aches and pains or even the very bad effects that we were told about.
MYERS
Let's go to the calls again, we go to Pamela Goring who's in West Sussex. Hello and Pamela your question please.
GORING
My cholesterol is quite good, it's 5.2, but that HDL is 2.72, LDL 2.25 and triclycerides are .5. But I do have other reasons for being at increased stroke risk. I've had conflicting advice as to whether statins would be a good idea. One consultant said it would because they would smooth the endoselium [phon.] and another consultant said he didn't think it was worth my taking them and that he thought they might actually reduce the HDL.
MYERS
It sounds as though you're very knowledgeable, you've got all the numbers and not a bad idea to know your numbers in the first instance, that's very interesting I think isn't it, but take us on to answering that question of whether lowering your cholesterol, taking statins, would be helpful to reduce your risk of stroke.
DAVIES
Well you win the prize for the best cholesterol telephoned in so far this afternoon. So a total of 5.3 is pretty good and you have an unusually high level of the HDL, which is the good one, so that protects you - that's fantastic. So I don't think you are at increased risk of stroke from the point of view of cholesterol.
GORING
I think I am for other reasons.
DAVIES
Can I ask what the other reasons are?
GORING
Well I've had a TIA in the past and also I've got some cardiac reasons. I've got mitrovalve prolapse and I've had a bout of AS recorded recently.
DAVIES
Ah you see we're getting off the subject of statins a little bit but I think the slightly leaky valve and the irregular heart rhythm combines to cause small blood clots and I think - so I don't think you need a statin but I think aspirin or warfarin is what you need. And so I think your stroke risk is not through the mechanism of a high cholesterol which you don't - in fact you don't have.
GORING
I have read that statins are thought to be beneficial for preventing strokes even if you don't need your cholesterol reduced, is that not correct?
DAVIES
I don't think so, no, it's people in whom the carotid arteries, the big arteries in the neck, are furred up with cholesterol, they're the people in whom statins help.
MYERS
Now I don't know whether Pamela had her measurements taken in the first instance at the local chemist but I know there are opportunities so to do Simon, would you encourage people to go and get their numbers from the pharmacist?
DAVIES
I have mixed feelings. I mean we're in a country, in a population, where there is so much heart disease and stroke that anything that gets people interested in their cholesterol has to be good. But there are slight concerns that the test done in the chemist when they prick your finger and take a drop of blood are not as accurate as asking your GP or the nurse to take a proper sample in a test tube and send it to a lab. And I think the test that you can have generally just give you the total cholesterol, they don't give you the balance of the good and bad. So better to walk into Boots and have it measured than not to have it measured but even better would be to go to your GP and have a really full measurement.
MYERS
And what do you make of Heather's e-mail? She's asking whether you should buy your statins across the counter - again you can go to a chemist and you can pick up a pack of statins, would you do that?
DAVIES
Personally I wouldn't but again anything that gets people thinking about this has got to be good. My slight concern is there'll be a few people who have got underactive thryoids and they're the people who might react badly. So I think the policy of perfection would be to see your GP, have a full blood test and have all these other things looked into at the same time.
MYERS
Okay, and we've got another call now from Andrew Beale, he's in Andover, question please Andrew.
BEALE
Good afternoon, thank you very much indeed. I'm on statins, no discernible side effects, but I read recently you should be wary of eating grapefruit, can you give me some information on that please?
DAVIES
Yeah, I think this isn't often important but grapefruit juice can contain a chemical that interferes with the statin, in fact it also interferes with a number of other drugs that are used for high blood pressure. So I think small amounts of grapefruit juice fine, but occasionally people are very keen on it have half a litre of grapefruit juice and that really does mess up the statin.
BEALE
I mean is half a grapefruit for breakfast each morning good or bad?
DAVIES
That's fine, in fact it turns out it's the pressed grapefruit juice that ...
BEALE
Oh no I don't have that.
DAVIES
So in fact if you're eating grapefruits it's unlikely you'd be eating so much grapefruit you'd have much of this chemical. Go for it.
BEALE
Well done. Thank you very much indeed.
MYERS
Thanks for that call and that is the last one, we've just got a few seconds to end off. But if you wanted to give a take home message, Simon, to our callers and those who've been listening this afternoon about their cholesterol - having it measured, having it treated - what's the take home message?
DAVIES
Exercise, have a good diet, at some point get your GP to measure a full cholesterol and go from there.
MYERS
Thank you very much indeed. Thanks to all our callers this afternoon and to all those who've taken the trouble to e-mail us. And thank you very much to Dr Simon Davies, our guest today. You can of course, as ever, listen to this programme again on our website, you go to bbc.co.uk and follow the trail to Check Up. You can get more information by calling our free and confidential help line, that's 0800 044 044. And join me again, if you will, at the same time next Thursday when we'll be taking your questions on stress.
ENDS
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