Anyone who takes cholesterol-lowering drugs must know the nocebo effect

Cholesterol is a vital building block in our body and important for the structure and function of body cells. That’s right. The fact that the vital functions of these blood fats speak for their general harmlessness and for the uselessness of cholesterol reduction, as is often claimed, is wrong and belongs to the realm of myth. The same applies to cholesterol as to many things: Too much is harmful.

High cholesterol levels – and this is where the “bad” LDL cholesterol comes into play – are damaging to our blood vessels, especially our coronary arteries. There is no doubt about that among specialists. Nature itself provides us with evidence of this. There are people who, due to special genetic predispositions, have high cholesterol concentrations in their blood.

Without early therapeutic countermeasures by lowering the elevated cholesterol levels, many of those affected often develop vascular diseases caused by cholesterol deposits at a young age. These form the basis for heart attacks and strokes. Conversely, people who have genetically low LDL cholesterol levels also have a remarkably low risk of heart attack.

Optimal Cholesterol: Why Statin Recommendations Have Been Adjusted

But when is cholesterol still normal and at what level is it too high? With this limit we are dealing with a so-called “moving target”. Initially, cholesterol-lowering statins were tested in studies on heart attack patients with cholesterol levels that are very high from today’s perspective, but were by no means rare at the time. Although lowering cholesterol levels resulted in a significant reduction in death and recurrence of heart attacks, there remained a significant “residual risk” of serious cardiovascular events.

Subsequent studies then attempted, starting from lower starting values, to further reduce this residual cardiovascular risk by lowering the cholesterol level even further. This has also been achieved with great success in studies. In this way, the target values ​​for the medicinal normalization of blood cholesterol levels have gradually been lowered further and further. How strict the cholesterol reduction should be also depends on how high the individual risk of a person is, for example because a cardiovascular disease already exists or not.

It may seem confusing or suspicious to many people that a cholesterol level that appears acceptable today will be considered too high tomorrow. I have explained that there are good reasons for this. Nonetheless, the “change in target values” for cholesterol reduction has attracted critics who suspect it to be a perfidious trick by the pharmaceutical industry, which is striving to increase pill sales. This too is a myth fueled by questionable media posts and blogs. The target values ​​have not been adjusted under pressure from the pharmaceutical industry, but have always been adjusted by international medical societies on the basis of the current scientific data situation – to the benefit of the patients.

Statins: The cholesterol-lowering drugs of choice

When it comes to normalizing cholesterol levels, doctors prescribe statins. Of course, an attempt should always be made beforehand or at the same time to reduce the cardiovascular risk through lifestyle measures such as a change in diet. However, the effect of diet on cholesterol is rather small and, especially in people at high risk, is usually not sufficient to bring cholesterol to the recommended low target level. In addition, medication is usually necessary here.

They are among the best-studied and tested drugs ever. The amount of data generated in many high-quality statin studies over the past decades is so large that the effect of cholesterol lowering on clinical events can now be quantified on this basis.

An international group of experts, the Cholesterol Treatment Trialists’ (CTT) Collaboration, has made calculations based on nearly 30 scientific studies involving more than 170,000 patients. Thereafter, treatment with statins that lowered blood LDL-cholesterol by 1 mmol/l (equivalent to 40 mg/dl) resulted in a reduction in fatal and non-fatal myocardial infarction, stroke, cardiac catheterization and heart disease in the treated group bypass operations by around 25 percent.

That’s the relative decrease. It should be borne in mind that in patients with a very high risk, in whom more cardiovascular events are to be expected in the future, more events are also prevented overall by statins with the same relative reduction. So the absolute benefit is greater here.

Statin intolerance is less common than previously thought

As with all medications, side effects can also occur when taking statins – for example as a result of interactions with other medications. However, there are also misconceptions about this. For example, statins have been linked to vitamin deficiencies and the development of dementia or cancer. This, too, falls into the myth category in the absence of scientific evidence.

The side effects of statins most frequently reported by patients are muscle pain, which can occur particularly with high doses. A “real” statin intolerance is probably much rarer than commonly assumed. This is the conclusion reached by a group of scientists who have compiled and evaluated data from 176 studies with around four million patients for an analysis. A statin intolerance based on the criteria of international professional societies was only found in five to seven percent of the patients. Well over 90 percent of all patients tolerated statins without any problems.

There are now clear indications that a so-called nocebo effect is often involved, for example in the case of muscular complaints when taking statins. It states that it is not the statin per se, but the perception of negative effects promoted by the media, hearsay or package inserts that leads to complaints.

In any case, it is striking that in so-called blinded studies, in which the patients do not know whether they are taking a statin or a dummy drug (placebo), the rate of muscle complaints is always very low. Once they become aware of statin use, complaints about related symptoms multiply. Complaints that can be assigned to the nocebo effect are also really felt by the patient. In any case, it is necessary for the doctor to clarify the reasons behind the symptoms. Direct muscle damage, for example through drug interactions, must be ruled out by the doctor.

Always consult a doctor before taking statins

It is urgently necessary to warn against permanently discontinuing statins on one’s own authority and without consulting the doctor due to alleged intolerances. Studies have shown that this can have dire consequences: the frequency of cardiovascular events then increases again. The principle still applies that man is as old as his vessels.