Choosing the Right Statin: High vs. Moderate vs. Low-Intensity Statins

• Statins are grouped into high, moderate, and low intensity based on how much they lower LDL cholesterol
  • High-intensity statins lower LDL by more than 50% (e.g., Atorvastatin 40-80 mg, Rosuvastatin 20-40 mg). They are for high-risk patients
  • Moderate-intensity statins lower LDL by 30-49%
  • Low-intensity statins lower LDL by less than 30%. They are for small reductions or intolerance to higher doses
• Doctors choose a statin based on how much cholesterol needs to be lowered and the patient's risk of heart disease. Maximally tolerated statin therapy should be used for high-risk patients to achieve ≥50% LDL lowering
• Statins are ecommended for individuals who:
  • Have high cholesterol
  • Have a history of heart problems
  • Patients with diabetes aged 40-75, regardless of LDL levels

Heart disease remains the leading cause of death worldwide, with high cholesterol being the biggest cause of heart disease. Nearly 2 in 5 adults in the United States have high cholesterol, yet many do not know it because there are no symptoms.

When bad cholesterol (LDL-C) builds up in your arteries, it can lead to heart attacks and strokes, which make up over 800,000 deaths each year in the U.S. alone.

Statins can lower your risk of heart attack and stroke by 20% to 30%, making them one of the most effective medications for heart health. But not all statins work the same way. Some lower cholesterol more aggressively than others, leading to the classification of high-intensity and low-intensity statins.

What Are Statins and How Do They Work

Cholesterol is a type of fat that your body needs, but too much of it in your blood can cause serious health problems. Statins work by lowering certain types of cholesterol and fats in your blood, which helps keep your arteries clear and reduces your chances of dangerous blockages.

Statins belong to a group of medications called HMG-CoA reductase inhibitors, named after the enzyme they block, HMG-CoA reductase. This enzyme controls how much cholesterol your liver produces. Since most of the cholesterol in your body is made in your liver, blocking this enzyme slows down cholesterol production.

As a result, your liver pulls more LDL cholesterol from your bloodstream, lowering LDL levels. Statins also help lower triglycerides and may slightly increase good cholesterol (HDL-C).

By reducing LDL and triglycerides while improving HDL levels, statins help prevent plaque buildup in your arteries. This lowers your risk of blockages that can lead to heart attacks and strokes.

What Is Statin Intensity?

Statin intensity refers to how much a statin lowers LDL cholesterol. It's is categorized into 3 groups: high, moderate and low. There are 7 types of statins, and their intensity depend on the type and the dosage. Some statins have a single intensity, while others span two.

For example, atorvastatin (Lipitor) at 10mg and 20mg is considered moderate intensity, whereas 40mg and 80mg are considered high intensity. High-intensity statins are more effective at lowering LDL-C, but they also carry a higher risk of side effects.

High Intensity: More than 50% LDL Reduction

These statins provide the most powerful reduction in LDL cholesterol. They are typically prescribed for patients at high risk of heart disease or those who have already had a heart attack or stroke.

• Atorvastatin (Lipitor) 40-80 mg
• Rosuvastatin (Crestor) 20-40 mg

Moderate Intensity: 30-49% LDL Reduction

These statins provide a moderate reduction in LDL cholesterol and are often prescribed for patients who need cholesterol control but do not require the strongest statin option.

• Pitavastatin (Zypitamag) 2-4 mg
• Rosuvastatin (Crestor) 5-10 mg
• Atorvastatin (Lipitor) 10-20 mg
• Simvastatin (Zocor) 20-40 mg
• Lovastatin (Mevacor) 40 mg
• Pravastatin (Pravachol) 40-80 mg
• Fluvastatin (Lescol) 40 mg twice daily or 80 mg extended-releas

Low Intensity: Less than 30% LDL Reduction

These statins have the mildest effect on LDL cholesterol and are usually prescribed for patients who need a small cholesterol reduction or cannot tolerate higher doses due to side effects.

• Simvastatin (Zocor) 10 mg
• Lovastatin (Mevacor) 20 mg
• Pravastatin (Pravachol) 10-20 mg
• Fluvastatin (Lescol) 20-40 mg

How Doctors Decide Which Statin to Prescribe

While high and moderate-intensity statins are recommended in most guidelines, low-intensity statins are now used mainly if patients cannot tolerate higher doses.

The goal is to use a statin strong enough to achieve a significant LDL reduction. The current guideline recommends the maximally tolerated statin should be used to reach the needed LDL lowering, ideally ≥50% for high-risk patients. If the preferred intensity is not tolerated, the next lower intensity, or dose, is used to still get some benefit.

Who Should take a Statin?

Statins are recommended for those who have high cholesterol, a history of heart problems, or conditions that increase your chances of developing heart disease.

• Heart disease or previous heart events: Anyone who has had a heart attack, stroke, or other heart-related conditions.
• High LDL-C: LDL cholesterol 190 mg/dL or higher, which may be due to a genetic condition (familial hypercholesterolemia)
• Diabetic patient between 40-75 and diabetic patients under 40 with additional risk factors such as high blood pressure, smoking, or obesity
• High risk of heart disease:

  Adults aged 40-75 with LDL cholesterol 70-189 mg/dL and a 10-year risk of a heart attack or stroke of 7.5% or higher (based on a risk calculator that considers factors such as age, blood pressure, smoking, and cholesterol levels)
  Those with a 10-year risk of 20% or higher almost always need a statin

• Patients with other risk factors:

  Chronic kidney disease (CKD) (especially moderate-to-severe stages)

  A family history of early heart disease (father or brother before age 55; mother or sister before age 65)

Who Should Avoid Statins?

Statins are generally safe and effective for lowering LDL cholesterol and reducing your risk of heart attacks and strokes.

However, some patients should avoid them due to medical conditions, side effects, or interactions with other medications. In these cases, alternative cholesterol-lowering options may be considered.

• Patients with active liver disease: Statins are processed in your liver. They can further stress your liver if you have active liver disease. Mild liver enzyme elevations are not a reason to stop statins, however, patients with persistent or worsening liver problems should avoid them.
• Patients who had severe muscle reactions to statins before: LStatins can cause muscle pain or weakness in some patients. In rare cases, they can lead to rhabdomyolysis, a serious muscle condition that can harm your kidneys. If a patient has had severe muscle pain, weakness, or dark urine while taking a statin before, they may need to stop and try alternative treatments.
• Patients who are pregnant or breastfeeding: Statins should not be used during pregnancy or while breastfeeding because they can affect the development of your baby.
• HPatients with severe kidney disease: While moderate kidney disease does not always require stopping statins, patients with severe kidney disease or those on dialysis may require a different approach.

Side Effects

Most patients tolerate statins well, but some experience side effects. These vary from mild to severe, and in rare cases, alternatives may be needed.

Common Side Effects

• Muscle pain and weakness: Soreness, cramps, or fatigue in your muscles, often mild but sometimes bothersome.
• Joint pain: Stiffness or discomfort in your knees, shoulders, or hands.
• Increased blood sugar: May affect or lead to diabetes in at-risk patients.
• Nausea, bloating, or diarrhea, usually temporary.

Rare, Serious Side Effects

• Rhabdomyolysis: Severe muscle breakdown leading to kidney damage, marked by extreme weakness and dark urine.
• Liver problems: Rare cases of liver inflammation; symptoms include jaundice or yellowing of your skin or the whites of your eyes, and dark urine.

Avoid grapefruit: It can interfere with how some statins are broken down in your body, increasing your risk of side effects.

Keep in mind that managing statin side effects often involves adjusting your medication rather than stopping it completely. Although, switching to a different statin can help, as some are better tolerated than others. Lowering your dose is another option, as it may still provide cholesterol- lowering benefits while reducing discomfort or issues.

Speak with Your Doctor

Statins play an important role in lowering cholesterol and reducing your risk of long-term complications. They are one of the most well-studied and widely used medications for managing cholesterol, with proven benefits for many patients.

While side effects are possible, most patients tolerate statins well, and adjustments can often be made if needed. If there are concerns about your statin treatment plan, your doctor can help find the right approach, and help you get the full benefit of your medication, whether that means adjusting your dose, switching to a different statin, or going over lifestyle changes that can support your heart health.