Experts debunk statin myths, stress life-saving benefits for diabetes patients

A red flag has been raised in the treatment of dyslipidemia, a chronic condition that almost always accompanies diabetes.

Even though diabetes patients need statin treatment to prevent cardiovascular disease due to elevated cholesterol levels proactively, the stigma associated with statins, which reportedly can cause muscle pain and raise blood sugar and liver levels, often prevents them from being treated properly.

Notably, diabetes patients with high levels of LDL (low-density lipoprotein)- cholesterol, a type of bad cholesterol, are at increased risk of cardiovascular disease and death. Due to misinformation about statins, however, some of these patients decide to stop taking statins, putting themselves at increased risk of cardiovascular disease.

“Diabetes patients who have already started taking statins have to take statins for life because they can't lower LDL cholesterol without taking medication,” said Professor Choi Sung-hee of the Department of Endocrinology at Seoul National University Bundang Hospital on the Korean Diabetes Association's YouTube channel. “The stoppage of statin (due to stigma of statins) makes it much more likely that patients will suddenly experience harmful effects, including myocardial infarction or arrhythmia, so it's important to consult with a doctor when stopping statins.”

Professor Hur Kyu-yeon of the Department of Endocrinology and Metabolism at Samsung Medical Center agreed, saying, “The problem is that patients who need active treatment are not getting it because they think everything is a statin side effect.”

Hur stressed that diabetes patients must lower their LDL cholesterol to a much lower level than the general population.

It's important to maintain a good and stable LDL cholesterol level without stopping statins because as soon as you stop statins, it can go right back up and put you at increased risk for cardiovascular disease," he added.

Are statins unnecessary for people with diabetes who have high LDL cholesterol because they increase the risk of muscle pain and significantly raise blood glucose and liver levels? No. The effectiveness of statins in patients with dyslipidemia has already been proven.

“Based on the current research, it is very clear that using statins to target LDL cholesterol is the most effective treatment, so I hope there is no confusion,” Professor Choi said.

Professor Hur said, “It is essential to lower cholesterol levels (in diabetic patients with high LDL cholesterol). It is also vital to actively use drugs that lower LDL cholesterol because drugs used to lower cholesterol are known to have multiple effects in addition to lowering cholesterol, including stabilizing blood clots, anti-inflammatory effects, and stabilizing vascular endothelial cells.”

Studies have shown that reducing LDL cholesterol levels by 40 mg/dL with statins in people with diabetes is associated with a 9 percent reduction in the risk of all-cause mortality and a 21 percent reduction in the risk of major vascular events.

Of course, statins are not without side effects. “Statins can cause muscle pain and a slight increase in blood sugar levels,” Professor Hur said, adding that liver levels may be elevated in rare cases.

However, the risks are small compared to the clear benefits of statins, and the myths surrounding statins are inaccurate and even exaggerated.

“When I compared a statin with a fake drug without knowing which one it was, I got the same muscle pain as if I had taken the fake drug, thinking it was a statin,” Professor Cho said. “This is a very well-recognized study that happens when you think about the risks of drugs with a nocebo effect."

The rate at which muscle pain develops into myopathy, a real risk, is also very low.

"It's rare for muscle enzymes to increase more than 10-fold, let alone 40-fold, and I've only seen one or two cases of rhabdomyolysis (muscle necrosis, a syndrome in which muscle components inside the cells are released into the blood) in over 20 years of clinical experience,” Professor Choi said. “It's deplorable that they're talking about a lot of side effects that are extremely rare."

Professor Hur said, "It's not easy for me to meet even one or two patients with rhabdomyolysis (a side effect of statin use). It's not that diabetes patients with dyslipidemia don't have muscle pain (as a side effect of statin use), but that the cause of muscle pain is likely not statins. There are so many conditions that statins can cause, so it is important to consult with your doctor to make sure that statin side effects do not cause the pain."

Professor Choi said, "There are many ways to identify myopathy, so I don't want people to self-diagnose and think they need to stop taking statins. It's a rare side effect, and there are ways to determine if it's a side effect.

Also, what's the truth about “elevated blood sugar,” another side effect of statins?

"It's not necessarily that statins raise blood sugar so much that you develop diabetes. Most patients who take statins already have conditions that predispose them to diabetes. Patients who are already obese, have pre-diabetes or high blood sugar, have high blood pressure, and are more likely to develop diabetes naturally, and they often have dyslipidemia, so I think there is a lot of misunderstanding," Professor Hur said.

Professor Choi also said, "If you take a statin in someone who has normal blood glucose levels and is not obese, and you take a statin in someone already pre-diabetic, the glycogenesis is significantly different. It's not that this information is wrong, but it's very misinterpreted. Moreover, high-dose statins are rarely used in Korea, and statin side effects are dose-dependent, so it would be good to discuss this with your doctor.”

The same goes for the stigma of elevated liver levels.

"Some foreign guidelines even say that you don't need to monitor liver function (for side effects)," Choi said. “With the newer statins, the side effects of elevated liver levels are extremely rare. You need to see at least a threefold increase in liver values to know if it's the drug or if it's something else, like fatty liver, or if you need to stop the drug, and in our experience, that's very rare."