Ezetemibe v atorvastatin

[Heartmum56]

Have had a meds review with cardiologist today. Lipids all good, ldl 0.9, trigs 0.5, total 2.5. Don't need both meds anymore. I was inclined to reduce atorvastatin because it's raising my liver enzymes and HbA1c but he said keep that and drop ezetemibe. He said ezetemibe reduced cholesterol but no evidence it reduces cardiovascular events. Does that fit with what any of you have been told? Statins apparently reduce cholesterol and cardiovascular events so he said better to keep that and not worry about the other blood results. Finding it a difficult one to weigh up.

[pasigal]

My suspicion is that what he means is that statins can make plaque more stable while ezetimibe is purely to lower LDL. Lower LDL has benefits but unstable plaque is a risk. Id ask him for clarification.

[JennyRx]

ezetimibe is usually used alongside statins when statins alone don’t lower LDL enough. It’s a different mechanism and it doesn’t stabilise plaque like statins. You would normally deprescribe ezetimibe before a statin as it’s really an adjunct to statin That’s what my lipidologist told me

[sandandkev]

Atorvastin affected my liver and although they said to carry on- I wasn't prepared to put my liver at risk so they put me on ezetimibe as its not a statin but reduces cholesterol but it gave me fatigue,I'm now on rosuvastatin which is ok, as far as I'm aware they both reduce cholesterol,don't know how statin would help heart though- you could ask pharmacist, I would get off Atorvastin and try a lower dose statin if needed

[Collectone]

Shocking that he told you not to worry about other blood results !!

[DWizza]

I have a high reading HbA1c that out as pre diabetic, my GP arranged another test as she couldn’t believe the result , it came back normal . I have had hip replacement surgery recently and they keep asking if I was diabetic .. definitely my statin , Rosuvastatin contributes. I have invested in a palm doc blood sugar monitor and tested over a day and had some normal readings . I will be monitoring over the next month to see if there is a pattern with particular foods or if the results stick to normal readings.

[Lowerfield_no_more]

From the NHS site here....

nhs.uk/medicines/ezetimibe/...

'Ezetimibe is a type of medicine used to lower cholesterol.

Cholesterol is a fatty substance in your blood that can block your blood vessels if levels become too high. This can make you more likely to have heart problems or a stroke'.

I suspect your cardiologist has not explained things very well, or it has been misunderstood.

My take is if ezetimibe and other lipid managing meds didn't reduce our cardio risk ,which is against all that we are led to believe by the medical evidence we are presented with, why are they so widely prescribed?

[Heartmum56 in reply to Lowerfield_no_more]

He was clear that it lowers cholesterol but seemed to be saying atorvastatin had additional benefits that ezetemibe doesn't have. He said just looking at the cholesterol numbers was not enough.

[Lowerfield_no_more in reply to Heartmum56]

The additional benefits are, as others have said, that statins apparently stabilise existing plaque so bits don't break off to cause blockages, which apparently ezetimibe doesn't do. So apart from the fact that statins are cheap, they are preferentially prescribed over other lipid managing meds because they do two things to reduce the heart health risk.

[pasigal in reply to Lowerfield_no_more]

Well, they do, somewhat. Especially if you have high cholesterol and you have not yet had a heart event or severe blockages. Ezetimibe's benefits are to lower LDL cholesterol, which is definitely associated with lower risk of cardiovascular disease. This is a recent good overview: health.harvard.edu/heart-he...

Here is the opening paragraph for the "tl;dr" crowd:

When it comes to reducing "bad" low-density lipoprotein (LDL) cholesterol levels, how low should you go? "People who are at high risk for cardiovascular diseases can benefit from driving LDL levels as low as possible to help reduce their risk for heart attacks and strokes," says cardiologist Dr. Christopher Cannon, editor in chief of the Harvard Heart Letter. "Across many large clinical trials, for LDL, the lower the better."

Ezetimibe can lower cholesterol for sure, so there is some benefit. The plus for statins is stabilizing existing plaque. Now, of course, there are many other factors, but looking over large populations, lower LDL is a benefit.

[Barre01]

statins have the added benefit of stabilising plaque, I understand.

[GoodTea]

Great that you have such low ldl-c levels (the 'bad cholesterol').

Regarding your concerns about your liver enzymes and HbA1c readings, perhaps you should ask your cardiologist if reducing the dosage of Atorvastatin while remaining on Ezetimibe would be reasonable.

My understanding is that initial studies showed low efficacy in reducing adverse CV (cardiovascular) events when Ezetimibe was used in isolation without statins. However, subsequent research showed that it boosted the effectiveness of statins in both reducing ldl-c and reducing adverse CV events while having a good safety record:

pubmed.ncbi.nlm.nih.gov/300...

pubmed.ncbi.nlm.nih.gov/326...

A recent review: pubmed.ncbi.nlm.nih.gov/388... (May, 2024)

has confirmed the point about one of the major benefits of combining Ezetimibe with statins which relates directly to your concerns about Atorvastatin and your liver + blood glucose levels:

"When combined with a statin, the statin dose could be lower, thus curtailing side-effects, while the hypolipidemic [lipid-lowering] effect is enhanced (by ~20%) ... "

I am in a similar position to you except for the fact that my ldl-c levels are a bit higher:

1.3 - 1.5 (wavering below and above the current 1.4 target).

My liver enzyme and blood glucose readings have been trending very slowly upwards since starting on Atorvastatin in March this year. Nothing serious or unexpected. Atorvastatin is known to lead to a marginal increase (3-4%) in blood glucose in some of us who take it.

I'm on Atorvastatin 80mg and have recently started taking Ezetimibe 10mg in the hope that my ldl will be reduced to around your levels.

At which point, if my liver and glucose readings are still trending upwards, I'll talk with my GP about whether it would be prudent to halve the statin dose while maintaining the Ezetimibe.

However, if my liver and glucose readings are stable, I will continue my current statin and Ezetimibe doses as there is a growing body of research showing that not only do statins stabilise the plaque in our arteries but they can also safely and substantially reduce some of the plaque.

If the research on plaque reduction is found to be robust, then we really will have something to feel hearty about!

[Heartmum56 in reply to GoodTea]

Thank you so much for this. I feel you understand what I am on about more than the cardiologist who was definitely more for keeping the statin and dropping the ezetemibe. I too read a lot of research papers though and my conclusion had been to stick with ezetemibe and lower the statin. He unsettled me on that. I hadn't seen your last article though which seems to confirm that I was right. I am currently on 40mg atorvastatin (reduced from 80 a year ago). Think I will now talk to GP about going down to 20mg atorvastatin and keeping the ezetemibe. Is that what you would do?

[GoodTea]

Glad my comments were of some use.

Re what I would do, I would definitely discuss it with my GP. He would be aware of my full range of health issues and how they would be impacted by alterations in the different medications. Also he would take into account the trends in the way my liver enzyme and HbA1c readings are rising and contrast it with the benefits of being on say 20mg Atorvastatin + 10 mg Ezetimibe vs 40mg Atorvastatin.

I would hope that if you set out the reasons for your preference for one option rather than the other, your GP would check with the cardiologist who would probably agree and ask for your 'bloods' to be monitored - as long as he could see no strong reason for objecting.

A strong reason might be that he or she thought diluting the strong anti-inflammatory actions of 40mg Atorvastatin would provide you with fewer benefits than 20mg Ator. + 10mg Ezetimibe despite the benefits regarding LDL-C reduction being similar or even superior with the latter treatment.

As you said in your first post, this is a difficult one to weigh up. I have looked through various research studies but am aware that I lack a clear picture of the overall context.

I'm lucky in that my GP and the cardiology team are willing to explain why one course of treatment is preferable to another and are also open - when appropriate - to agreeing to change dosage/medications and monitor the outcomes. I hope that your GP and cardiologist are similar in that regard.