Monday , December 11 2017
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Statins and Exercise: Revisited

By Sheri R. Colberg, PhD

I chronicled someone with type 1 diabetes whose ability to exercise was compromised by his use of statins back in April 2016 (http://www.diabetesincontrol.com/what-you-dont-know-about-statins-and-exercise-can-hurt-you/). As you know, statins are a class of medications prescribed to lower cholesterol levels or abnormal levels of blood fats, with the goal being a reduction in the risk of heart attack and stroke. Brand name examples of statin medications include Altoprev, Crestor, Lescol, Lipitor, Livalo, Mevacor, Pravachol, and Zocor.

The updated cholesterol guidelines have led to even more adults with diabetes and prediabetes being put on various medications from this class. For individuals who are unwilling or unable to change their diet and lifestyles sufficiently or have genetically high levels of blood lipids, the experts have claimed that the benefits of statins for lowering cardiovascular risk likely greatly exceed the risks (1). If those risks include the risk of becoming more inactive, then I vehemently disagree with this claim.

This issue is resurfacing for discussion because of a recent study in JAMA Internal Medicine online ahead of print in May 2017 (2). The goal of that study was to examine statin treatment among adults aged 65 to 74 years and 75 years and older when used for primary prevention in the Lipid-Lowering Trial (LLT) component of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. The statin in the study was pravastatin (Pravachol), and the adults already had elevated LDL levels and hypertension in most cases. Interestingly, over a six-year period, taking that statin did not lower the risk of having a coronary heart disease event compared to usual care in these older individuals (some of whom likely had diabetes or prediabetes, although this was not stated).

That said, if statins don’t always prevent coronary events, then what is the benefit of prescribing someone this medication that may keep him or her from being active and naturally lowering their cardiovascular risk with physical activity? It may be that glucose, blood pressure, and cholesterol all need to be aggressively managed in order to see benefits, as other studies have suggested, but then why not try to do that with exercise and physical activity (which can lower all three)? As I stated before, likely the greatest risk factor for heart disease is physical inactivity, so prescribing statins that make people sedentary is counterproductive. At least have them try another medication to see if it has a lesser negative impact on being active.

In addition, we already know that many statins increase the risk of developing type 2 diabetes (3). A recent meta-analysis of 20 studies just reported an increased risk of new-onset diabetes from 9% to 13% associated with statins over just a one-year period, and the researchers admitted that this could be an underestimation of the risk of developing type 2 diabetes due to statin use (4). Diabetes is known to be a strong and independent risk factor by itself for cardiovascular disease. Does this make the “cure” for high LDL-cholesterol worse than the condition itself?

As a group of medications, statins are recognized for frequently causing muscle and joint issues. Muscular effects from statin use, such as unexplained muscle pain and weakness, are common and may result from a compromised ability to generate energy. The occurrence of muscular conditions like myalgia, mild myositis, severe myositis, and rhabdomyolysis, although relatively rare, is doubled by diabetes (5). Others have reported an increased susceptibility to exercise-induced muscle injury when taking statins, particularly active, older individuals (6). Other symptoms, such as muscle cramps during or after exercise, nocturnal cramping, and general fatigue, generally resolve when people stop taking them. It is also concerning that long-term use of statins negatively impacts the organization of collagen and decreases the biomechanical strength of the tendons, making them more predisposed to ruptures. Statin users experience more spontaneous ruptures of both their biceps and Achilles tendons (7-9). Again, I can only recommend that people talk with their doctors about whether it may be possible to manage their cardiovascular risk and lipid levels without taking statins long-term for this reason.

If people experience any of these symptoms, they should talk with their healthcare provider about switching to another cholesterol-lowering drug. A newer one on the market that is not a statin is Repatha (evolocumab) and is worth a look if such medications absolutely have to be taken. Instead of blocking LDL production by the liver like most statins do, Repatha apparently is an injectable antibody that helps the liver clear LDL by limiting the actions of PCSK9 and lower blood levels of LDL. While its musculoskeletal effects remain to be determined (if any), it appears that it is unlikely to do more harm than statins. No such side effects are listed as common on the packaging in any case. It’s worth considering…

References cited:

  1. Kones R: Rosuvastatin, inflammation, C-reactive protein, JUPITER, and primary prevention of cardiovascular disease–a perspective. Drug Des Devel Ther 2010;4:383-413
  2. Han BH, Sutin D, Williamson JD, Davis BR, Piller LB, Pervin H, Pressel SL, Blaum CS, ALLHAT Collaborative Research Group: Effect of Statin Treatment vs Usual Care on Primary Cardiovascular Prevention Among Older Adults: The ALLHAT-LLT Randomized Clinical Trial. JAMA Intern Med. 2017 May 22. doi: 10.1001/jamainternmed.2017.1442. [Epub ahead of print]
  3. Mayor S: Statins associated with 46% rise in type 2 diabetes risk, study shows. BMJ 2015;350:h1222
  4. Casula M, Mozzanica F, Scotti L, Tragni E, Pirillo A, Corrao G, Catapano AL: Statin use and risk of new-onset diabetes: A meta-analysis of observational studies. Nutr Metab Cardiovasc Dis. 2017 May;27(5):396-406. doi: 10.1016/j.numecd.2017.03.001. Epub 2017 Mar 10.
  5. Nichols GA, Koro CE: Does statin therapy initiation increase the risk for myopathy? An observational study of 32,225 diabetic and nondiabetic patients. Clin Ther 2007;29:1761-1770
  6. Parker BA, Augeri AL, Capizzi JA, Ballard KD, Troyanos C, Baggish AL, D’Hemecourt PA, Thompson PD: Effect of statins on creatine kinase levels before and after a marathon run. Am J Cardiol 2012;109:282-287
  7. de Oliveira LP, Vieira CP, Da Re Guerra F, de Almeida Mdos S, Pimentel ER: Statins induce biochemical changes in the Achilles tendon after chronic treatment. Toxicology 2013;311:162-168
  8. de Oliveira LP, Vieira CP, Guerra FD, Almeida MS, Pimentel ER: Structural and biomechanical changes in the Achilles tendon after chronic treatment with statins. Food and chemical toxicology : an international journal published for the British Industrial Biological Research Association 2015;77:50-57
  9. Savvidou C, Moreno R: Spontaneous distal biceps tendon ruptures: are they related to statin administration? Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand 2012;17:167-171

In addition to my educational web site, Diabetes Motion (www.diabetesmotion.com), I also recently founded an academy for fitness and other professionals seeking continuing education enabling them to effectively work with people with diabetes and exercise: Diabetes Motion Academy, accessible at www.dmacademy.com. Please visit those sites and my personal one (www.shericolberg.com) for more useful information about being active with diabetes.