Medication Review: Statin Class
Medication Review: The Statin Class
What are statins?
-Statin medications are some of the most common medications that prehospital providers encounter in patient populations. Statin medications are prescribed primarily for hypercholesterolemia conditions. However, it can also be used for conditions like hyperlipidemia. It can also be prescribed by primary care providers for continual maintenance and protection of patients with significant family health history.
What is hypercholesterolemia?
Hypercholesterolemia is the medical term for excess cholesterol circulating in the blood. It specifically refers to excess LDL - low density lipoproteins. This is the “bad” kind of cholesterol that can increase overall health risks in excess. HDL - high density lipoproteins - is another value that is assessed when evaluating a patient for potential lipoprotein diseases. Someone is officially diagnosed as having hypercholesterolemia at 190mg/dl of LDL. Someone can also be diagnosed based off risk factors such as familial hypercholesterolemia issues or previous cardiac events (Family Heart Foundation).
Hypercholesterolemia puts patients at increased risk for thrombotic/embolic issues such as MI, DVT, or stroke. High LDL levels increases the production of plaque within arteries, narrowing the lumen and reducing perfusion with time. Patients with untreated hypercholesterolemia are likely to develop atherosclerosis Patients with hypercholesterolemia often develop hypertension as a result of this narrowing. This plaque can break off and become an embolism as it travels upwards in the body.
Hypercholesterolemia is particularly dangerous because it does not have any symptoms alone. It is commonly recognized through routine lab testing or when it leads to the development of another symptomatic condition such as heart disease.
What is the mechanism of action of statin drugs?
Statins work by stopping the HMG-CoA reductase enzyme. This enzyme is used to break down mevalonate as part of a metabolic process called the mevalonate pathway. This is the means through which the body processes fats and proteins in the diet and converts it to usable functional lipids for the body. By blocking this enzyme, less mevalonate is broken down and thus less lipids overall are produced. This drops cholesterol production in the body.
Image sourced from Researchgate.net.
The above image shows the role of statin drugs in the mevalonate pathway.
What populations is hypercholesterolemia and statin use common in?
Hypercholesterolemia is incredibly common in the United States - in fact, over 27 percent of adult Americans hit the diagnosis criteria for hypercholesterolemia by lab results alone (CDC). It is most commonly seen in older, sedentary adults with poor dietary habits. Occurrence is common in all populations, but highest in non-Hispanic white females (CDC).
Statin prescription is one of the most common means to address high LDL issues. Additional components of hypercholesterolemia management includes exercise prescriptions, weight management, managing and modifying diet habits, and conducting more regular PCP follow-ups to assess for risk of heart disease.
Recognizing Statin Drugs
Statin medications are easily recognized by their -statin suffix. A variety of generic and brand name statin medications are available in the United States, usually at relatively low cost. Some of the most common statin medications prescribed in the United States include Lipitor (generic name: atorvastatin), Crestor (generic name: rosuvastatin), pravastatin, and Zocor (generic name: simvastatin).
EMS Provider Considerations
Long-term or heavy statin drug use can have a significant impact on patient’s renal health. The risk of renal injury increases with the intensity of the dose (Tonelli et al., 2019). Women, diuretic users, and ACE inhibitor users are at increased risk (Tonelli et al., 2019). This makes patients overall more medically fragile and increases the risk for requiring dialysis or further renal care in the future. The longer someone is on a high dose of statin medications, the higher risk for renal injury and eventual renal failure. Primary care providers are aware of this and work with patients to manage the benefits of reducing LDL versus statin medications’ renal function effects.
Statin has also been linked to myopathic effects and damage to skeletal muscles. It increases the risk of myositis, with one of the major complaints of statin users being muscular pain or weakness (Selva-O'Callaghan et al., 2018). In severe cases, this muscular damage combined with the risk of acute kidney injuries can put patients at risk for rhabdomyolysis.
EMS providers should have a generally increased index of suspicion for those with overall poor health and long-term statin use. Statin users are particularly at risk of rhabdomyolysis and hyperkalemic conditions after periods of prolonged sedentary states such as being bedridden or being immobile following a fall. Pancreatitis has also been observed in statin users, although with low incidence (Kuoppala et al,. 2015). Dark urine and signs of potential acute abdomen are also something EMS providers should be aware of.
Works Cited
Centers for Disease Control and Prevention. (2021, September 27). High cholesterol facts. Centers for Disease Control and Prevention. Retrieved February 19, 2022, from https://www.cdc.gov/cholesterol/facts.htm
FH diagnosis, management and family screening. The Family Heart Foundation. (2021, December 2). Retrieved January 19, 2022, from https://thefhfoundation.org/diagnostic-criteria-for-familia-hypercholesterolemia2
Gu, Q., Paulose-Ram, R., Burt, V. L., & Kit, B. K. (2014, December). Prescription cholesterol-lowering medication use in adults aged 40 and over: United States, 2003-2012. NCHS data brief. Retrieved January 18, 2022, from https://pubmed.ncbi.nlm.nih.gov/25536410/
Ibrahim, M. A. (2021, November 7). Hypercholesterolemia. StatPearls [Internet]. Retrieved January 18, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK459188
Kuoppala, J., Pulkkinen, J., Kastarinen, H., Kiviniemi, V., Jyrkkä, J., Enlund, H., Happonen, P., & Paajanen, H. (2015). Use of statins and the risk of acute pancreatitis: A population-based case-control study. Pharmacoepidemiology and Drug Safety, 24(10), 1085–1092. https://doi.org/10.1002/pds.3858
Roland, J. (2022, January 27). Statin side effects: What you need to know. Healthline. Retrieved January 17, 2022, from https://www.healthline.com/health/high-cholesterol/statins-list-of-common-types#side-effects.
Selva-O’Callaghan, A., Alvarado-Cardenas, M., Pinal-Fernández, I., Trallero-Araguás, E., Milisenda, J. C., Martínez, M. Á., Marín, A., Labrador-Horrillo, M., Juárez, C., & Grau-Junyent, J. M. (2018). Statin-induced myalgia and myositis: An update on pathogenesis and clinical recommendations. Expert Review of Clinical Immunology, 14(3), 215–224. https://doi.org/10.1080/1744666x.2018.1440206
Tonelli, M., Lloyd, A. M., Bello, A. K., James, M. T., Klarenbach, S. W., McAlister, F. A., Manns, B. J., Tsuyuki, R. T., & Hemmelgarn, B. R. (2019). Statin use and the risk of acute kidney injury in older adults. BMC Nephrology, 20(1). https://doi.org/10.1186/s12882-019-1280-7
