Should I take statins? I’m weighing up the pros and cons before I commit

I’ve been advised to go on statins to lower my cholesterol. I ask the experts whether they’re a quick fix – or a risk to my health

Around eight million people in the UK are on statins, and I may soon have to join them. The results of a couple of blood tests have told me I have “high cholesterol” and I’ve been advised that going on these tablets will lower my risk of heart attacks or strokes. Surely this is what they call a “no-brainer”?
Statins are medications used to lower the level of cholesterol in the blood and protect the insides of the artery walls. All the experts agree that having some cholesterol in your body is necessary and healthy. But having too much of the “wrong” type of cholesterol over time can clog a person’s arteries and lead to problems.
People are advised to take statins (drugs including atorvastatin, fluvastatin, and pravastatin) for several reasons. They already may have had a heart attack or a stroke. Or they may have diabetes, suffer with angina or peripheral arterial disease, or be at high risk of having a cardiovascular event.
I am fit and healthy. I don’t smoke and have no symptoms of heart disease. But I’m a bit overweight and my father has high cholesterol – it can run in families. Those blood test results – particularly regarding the level of my LDL (or ‘“bad” cholesterol) – suggest I might be heading in a risky direction at the age of 56.
The question is: do I really want to start taking statins (which like all medications can have side effects) for the rest of my life? More importantly, do I actually need to?
It’s hard to get an unequivocal answer to this question. In one corner, you have conventional medics like my brother, Miles, 53, a professor and a hospital consultant. Miles tells me he’s going to go on statins “automatically” at 55 because of the clear benefits they confer.
Then there are people like a nutritionist I met at a party who threw into conversation that statins are to be avoided at all costs, because they “cause diabetes, dementia and dry your brain out.” The latter, in particular, sounded somewhat unscientific, but it was certainly alarming.
According to a 2023 survey of half a million adults by Our Future Health, 54 per cent of adults are said to have “high total cholesterol levels”. An NHS study a year earlier showed that 72 per cent of people aged between 45 and 56 have “raised cholesterol”. (It was slightly lower in the older age-groups, probably because many of them are on statins).
Hence, I know I’m not alone in having to make this decision. So what is a midlifer in my position to do?
Robin Choudhury is a professor of cardiovascular medicine at the University of Oxford, a consultant cardiologist at John Radcliffe Hospital and the author of The Beating Heart: The Art and Science of Our Most Vital Organ. “A quarter to a third of all people will suffer from a cardiovascular event over their lifetime, or die from such an event,” he says.
“A very important thing about statins is that they are drugs with an enormous evidence database. We have more consistent data about statins than almost every drug we use, in the form of tens of thousands of patient data years.”
Prof Choudhury describes his “Kennedy assassination moment”, early in his career. “I was working as a young doctor at the Royal Brompton hospital in 1994 when then the 4S study [Scandinavian Simvastatin Survival Study] was published in The Lancet,” he says.
The 4S study provided strong evidence that lowering cholesterol could prolong life in people who had high cholesterol and had a heart attack. “There had been some doubt before that, so it was a big deal,” Prof Choudhury explains.
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The 4S study was followed a year later by the West of Scotland Coronary Prevention study (WOSCOPS) which revealed significant benefits for people who hadn’t yet had a heart attack or a stroke. Statins also reduced the overall risk of death by coronary heart disease by 28 per cent, and reduced the risk of death by other cardiovascular disease by 25 per cent amongst those with very high LDL cholesterol.
“A 20-year follow up from that study showed that early intervention also paid back benefits,” says Prof Choudhury.
So why not put everyone on a statin? “When we start statins, we need a clear idea of what the objectives are – whether to decrease your risk of current heart attack or to maintain cardiovascular health,” says Prof Choudhury. “But your cholesterol levels should not be viewed in isolation. They need to be interpreted with an individual’s other risk factors and health attitudes, in a holistic sense.” The higher the risk of a heart attack or stroke, the more beneficial statins become, he adds.
Most clinicians now consult an algorithm called the QRisk. A health professional will measure your blood pressure, cholesterol, height, weight and waist circumference, and ask questions about smoking, alcohol consumption and exercise. These are put into a computer and calculate your ‘QRisk’ score, which is your risk of a cardiac ‘event’ in the next 10 years.
A low QRisk score of less than 10 per cent means that you have less than a one in 10 chance of having a stroke or heart attack in the next 10 years and a higher QRisk score of more than 20 per cent means that you have at least a two in 10 chance of having an event in the next 10 years.
On the NHS, statins are generally prescribed if a person has a QRisk of over 10 (in the United States, it’s lower, at 7.5 per cent). “The threshold is somewhat arbitrary,” states Prof Choudhury.
My most recent QRisk score, calculated in February 2024, was 9 per cent: just under the NHS wire.
But among what looks like overwhelming evidence that statins can be life-saving, a growing amount of scepticism is brewing. Critics argue that perhaps these pills are being doled out too liberally and that lots of people shouldn’t be on them at all.
Others think that statins may even be bad for us. In his 2014 book The Great Cholesterol Con, the Scottish GP Malcolm Kendrick argues that high cholesterol levels don’t cause heart disease, that statins have many more side effects than has been admitted and their advocates should be asking more questions.
Prof Gareth Morris-Stiff is a consultant liver surgeon at the Cleveland Clinic Lerner College of Medicine in Ohio and the global chief medical officer of Equilibrium. “The data on statins isn’t perfect,” he explains. “These drugs aren’t for everyone. As we know, all drugs can cause side effects. The problem arises when you give them to everyone without discrimination which is more the case in the US, but increasingly in the UK. I don’t think it’s correct for the message to be: ‘everyone should have a statin’.”
Common statin side effects include muscle pains, weakness and stiffness. “They can also lead to transient liver dysfunction,” says Prof Morris-Stiff. “Statins are well known to raise certain liver enzymes. In the short-term, this may be insignificant, although we are not certain. But in the long term, patients on statins may develop liver fibrosis presumably caused by inflammation. Statins don’t prevent the development of fatty liver disease, and could indeed promote it.” Conversely, some recent studies suggest statins may have a protective effect on the liver.
Prof Morris-Stiff feels there haven’t been enough studies to show the long-term effects of statins on the liver. “The relationship between cholesterol, statins and liver disease isn’t clear, and the waters are muddy,” he says.
He cites a former patient who had been on statins for 26 years, and had regular liver tests which, on close examination, showed serious liver abnormalities. “You can’t say 100 per cent that he didn’t have this problem before going on statins, but the link needs to be ruled out,” he says. “All patients with metabolic syndrome [a cluster of conditions that increase your risk of heart disease, stroke or diabetes] should have a liver screen at baseline before starting statins.”
Prof Morris-Stiff describes what he sees as “an obsession with fat and cholesterol”. “Statins have made billions for Big Pharma,” he says. “There is now a philosophical discussion about cholesterol and statins because in the late 1970s and 1980s we were told ‘fat is bad’ for you. We were also told we should switch fats to carbs and have three square meals. [Yet] there has been a rise in obesity.”
In Prof Morris-Stiff’s opinion, the focus on fats and cholesterol is misplaced and that the real issue is sugar, and a diet high in carbohydrates. “My big concern is insulin resistance, and accelerated diabetes in ethnic groups such as those from the Indian subcontinent because they can’t process carbs as efficiently and have increased risk for metabolic syndrome,” he notes.
Prof Morris-Stiff would like to see more research detailing who benefits from statins, and who is most at risk from side effects. “We need to identify a biomarker for the response to statins,” he says. In the meantime, he would like people to consider alternatives.
A 2022 study in the journal Pharmacological Research found that taking plant sterols (or extracts) can cause a modest reduction of LDL cholesterol. Prof Morris-Stiff points to other papers in nutritional journals pointing out the usefulness of herbal remedies including ginseng and curcumin in lowering cholesterol.
“Herbs don’t treat disease but they address the balance,” explains Prof Morris-Stiff. “We describe these as ‘phytomedicines’: we are not allowed to say they treat cholesterol.”
Can natural medications really take the place of pharmaceuticals? “The first thing to say is that people should be sensible,” says Prof Morris-Stiff. “For example, if you have genetically high cholesterol, you must talk to your doctor. But before automatically starting drugs with documented long and short-term side effects, we should address the underlying issues with diet and exercise, seek to modify them, and exhaust these options first.”
Conventional medics continue to counter some of the more florid claims made against statins.
“Some people have scepticism about Big Pharma, perhaps because the use of these drugs is so widespread,” Prof Choudhury observes. “But, again, the response is to go to the hard data – there is so much of it. You have to look at the quality of the evidence.”
Prof Choudhury accepts that some patients do suffer from muscle pain as a result of taking statins, and that there is low risk of a serious muscle inflammation termed rhabdomyolysis. “But that’s 1.5 per 100,000 people treated,” he says. “There is some evidence that statins increase the risk of diabetes by a small amount [about one per 200 treated in one particular clinical trial], but the net effect was still very beneficial and average glucose levels were unchanged.
“There is no evidence that statins cause cancer, or that they cause dementia,” Prof Choudhury adds.
Amitava Banerjee is a professor of clinical data science at University College London and honorary consultant cardiologist at University College London Hospitals and Barts Health NHS Trusts. “It’s OK to ask questions, but we need to have a framework,” he says.
“When deciding whether information is worth taking seriously, I apply a really simple algorithm: have I been presented with credible evidence? What expertise does the source have? How much experience do they have? Have they just watched a YouTube channel? Do they lack one or all of the above? Do they have a book to sell?
“People might say: ‘I like the natural treatment’ but any systematic review has to be independent,” he notes. Prof Banerjee has “no problem” with lifestyle solutions or functional medicine. “It isn’t an either/or,” he says. “You can take a statin and live healthily. The problem is that the critics are presenting a world where there’s an either/or and this isn’t evidence-based.
“There is a misunderstanding of the evidence in some circles,” he continues. “It’s possible that some practitioners overplay the importance of lifestyle interventions, which may not work as well as we get older. Diet or exercise just may not be enough in some people.”
Prof Choudhury emphasises the importance of a patient being “on board” with starting a statin. “The evidence shows that people are more likely to comply with long-term preventative medicine if they are in favour of it,” he says. “It’s not my job to tell people what to do, or to push a drug. The patient makes the decision. Maintaining trust is the key to the doctor/ patient relationship. These drugs are not a life sentence.
“I would advise a patient to become informed and see a practitioner they trust and who will provide them with evidence-based advice on which to base their decision.”
All of which still leaves me with that decision of my own.
I haven’t consulted a doctor since my borderline QRisk ‘nine’ at the start of the year. But, in the past few months, I’ve lost close to a stone in weight. So though the ‘age’ part of the algorithm will have gone up, chances are, I’m still on the right side of the NHS equation. For now, I’m sticking with the lifestyle, diet and exercise option. As for the future? My mind remains open and I may still go on statins one day.