Disclaimer: This article is written to serve as a source of perspective based on my view and the existing scientific evidence. On no account should it be used as medical advice. My advice is for everyone to consult their medical doctor to seek the unsurpassed personalized treatment option.
Recently, I published a couple of articles focusing on statin cholesterol-lowering agents’ potential benefits and untoward side effects.
Statins are the layperson name given to HMG-CoA reductase inhibitors, such as Atorvastatin, Rosuvastatin, Simvastatin, Cholesterol, Fibrate, Ezetimibe, Pravastatin, and more. They are a class of lipid-lowering medications that reduce illness and mortality in those at high risk of cardiovascular disease. Today, Statins are among the utmost used drugs to avert unfavorable cardiovascular incidents.
Unfortunately, statins received a US Food and Drug Administration alert in 2012, scrutinizing the increased risk of incident diabetes and making blood glucose control even harder in patients who already have diabetes. It is also speculated; statins of the various families differ concerning their diabetes causing potential. Since there is also an increased association between diabetes and cardiovascular disease (CVD) and elevated cholesterol, drawing the clinical decision line as to whom to treat with statins today is an intricate decision.
Presently multiple clinical reviews are trying to fine-tune the clinical decision on statin therapy.
Evidence pointing toward the Diabetogenic effect of the Statins
Diabetes causing effect of statins didn’t recurve much attention until 2008, of results of the Intervention Trial Evaluating Rosuvastatin (JUPITER), were conducted and reported. The latter was a large, randomized, placebo-controlled, primary prevention trial. The study revealed an Increased incidence of diabetes in persons taking rosuvastatin (a type of Satin) was reported in this trial,
Previous to the JUPITER study, the West of Scotland Coronary Prevention Study (WOSCOP) study (2001) reported a 30% risk reduction for diabetes with pravastatin. But conversely, the study found a 32% higher incidence of diabetes with pravastatin therapy for the elderly. Furthermore, long-term Pravastatin therapy observation naked no reduction in the incidence of diabetes in the long-term intervention with pravastatin in the ischemic disease trial.
There have been at least another three studies with various sets of outcomes regarding linking statins with diabetes.
A Statin therapy meta-analysis of five studies demonstrates a 13% increase in diabetes risk with no array across trials. However, the analysis also concludes; that when data from WOSCOP was incorporated, the danger became statistically trivial. Then again, another meta-analysis by Sattar et al. included 13 randomized placebo-controlled and standard care-controlled trials with 91,140 participants. The study indicated a 9% expanded risk of diabetes incidence with little heterogeneity between trials.
Another study carried out by Preiss et al. in 2011 confirms that a higher statin dosage carries a higher diabetogenic effect with a 12% higher risk on intensive-dose statin therapy than moderate-dose treatment.
Statins may potentially affect Blood Glucose Homeostasis
Some studies substantiate the theory that statins may modify glucose homeostasis by both impairing insulin secretion and diminished insulin sensitivity of the cells. Possibly statin induces diabetes. Amid the cholesterol synthesis process (from acetyl CoA), numerous byproducts such as Isoprenoid, Farnesyl pyrophosphate, Geranylgeranyl pyrophosphate, and Ubiquinone (Coenzyme Q10 [CoQ10]) are affected. The latter, in turn, tend to hinder insulin secretion or action. For instance, statins are known to deplete CoQ10 levels, which is a component of the biochemical chain of development involved in the process of ATP (a cell energy factor) generation. Curtailed levels of CoQ10 can result in delayed production of ATP and consequently diminish insulin release.
Furthermore, statins down-regulate a factor called GLUT4 in fat cells. GLUT4 mediates insulin-stimulated glucose uptake by skeletal muscles and adipocytes. Atorvastatin and Simvastatin have been shown to decrease the expression of GLUT4 in adipocytes which may result in impaired glucose tolerance.
Adiponectin is an insulin-sensitizing and anti-inflammatory cytokine typically released from fat cells. Rosuvastatin and Simvastatin have decreased plasma adiponectin levels and insulin sensitivity, while pravastatin increased both.
Statins may also cause Mitochondrial dysfunction in cells that produce insulin (beta cells of the pancreas), skeletal muscles, and fat cells. In addition, statin-induced myalgia and fatigue may impair exercise capacity and aggravate sarcopenia, associated with glucose intolerance and type 2 diabetes.
Some Statins may be better than others
There are generally two chemical forms of statins; fat-soluble (lipophilic) and water-soluble (Hydrophilic) Statins.
Statin medications: Atorvastatin, Simvastatin, lovastatin, Fluvastatin, and Pitavastatin are relatively lipophilic in chemical structure, while pravastatin and rosuvastatin are relatively hydrophilic.
It has been deduced that lipophilic statins are probably more diabetes-causing. Because they readily penetrate liver cell membranes such as beta cells, adipocytes, and skeletal muscles.
Therapy with Statin Drugs necessitates a personalized Approach
For many reasons Association of statin use with new-onset diabetes presents a predicament for the physician.
- diabetes is equivalent to coronary heart disease risk
- High cholesterol level is a distinct feature of diabetes
- persons at risk for CVD (including persons with Dyslipidemia) may be prediabetic and finally
- risk factors for diabetes and CVD are overlapping.
It seems that treatment with statins may metaphorically be a double-edged sword as it is hard to delineate when to Prescribe only when indicated clearly. Reports suggest that statins are prescribed liberally when used when there is a clear therapeutic rationale. However, that justification will never come to us if we continue the path of statistics.
True, it is always logical if we Start with low doses to reduce higher risk. Likewise, High dose statins are better averted in women and the elderly. Also, water-soluble ones may be better all with lifestyle modification
The benefits of regular exercise and dietary changes should be stressed at every contact with the patient.
It is the prevailing standard to enlighten patients about the risk and benefits of statin therapy and consider risk factors. Still, all said and done none will be possible without personalizing the medical care.
Before starting statin therapy, screening for type 2 diabetes may be a good idea, and monitoring all patients on intensive-dose statin therapy should be regularly monitored using fasting glucose level and HbA1c, but that is not enough. Or supplement them with Vitamin D to avoid deficiency which has been linked with insulin resistance.
It is time to reform the Healthcare delivery model, as the population health is flunking to meet 21st-century healthcare needs. The latter is the upshot of the raised knowledge base and public access to information.
Today, millennials have the latitude of individual expectations. Population health has run reasonably well since its advent in the 1900s. It helps reduce healthcare costs as long as the citizens follow the One-Size-Fits-All pattern of the scheme. But on the downside, population health tends to leave out the minority crowd and the vulnerable in exile.
Personalized healthcare pertains to discrete individual scenarios. It is about how an individual’s perception influences clinical decision making, something not particularly experienced today by the patients, expected by physicians, and defined by 3rd party entities. A personal opinion of the quality and value of service and commodity bears or correlates only to one singular personage rather than to a profile of people as a group.
Personalized Healthcare utilizes the latter concept to transform patients’ experiences by delivering medical care tailored to the individual, thereby bettering treatment, circumventing obstacles, and diagnosing more efficiently and expeditiously.
Conventional population-focused Healthcare is characterized as a passageway to providing patient care that concentrates on an entire community with a particular predetermined profile, rather than solely centering on individualized patient care.
The supporters of population health are professedly hesitant to recognize the current wants. And to improve by the so-called presumptuousness of utility challenges linked with personalized healthcare. Yet, they are radically implementing value-based models and patient engagement programs merely the composite of population and “personalized” healthcare intuition. Such a system may indeed attend well in the short run for a healthcare system in transition to personalized healthcare, but if the development deadlocks at some point, it will also falter in the long term.