Should we lower cholesterol as much as possible?

doi:10.1136/bmj.332.7553.1330

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Uffe Ravnskov (ravnskov@tele2.se), independent researcher1,
Paul J Rosch, clinical professor2,
Morley C Sutter, professor emeritus3,
Mark C Houston, clinical professor of medicine4

¹ Magle Stora Kyrkogata 9, S 22350 Lund, Sweden,
² Departments of Medicine and Psychiatry, New York Medical College, Valhalla, NY, USA,
³ Department of Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver BC, Canada,
⁴ Vanderbilt University School of Medicine, St Thomas Hospital, Nashville, TN, USA

Correspondence to: U Ravnskov

Accepted 28 April 2006

Statins are portrayed as harmless drugs that almost everyone would benefit from, but little is known about the side effects at the high doses now being suggested

People at high risk of cardiovascular disease should be treated more aggressively. This is the message from the American National Cholesterol Education Program published last year.1 By aggressively, it means that low density lipoprotein (LDL) cholesterol concentrations should be lowered to less than 1.81 mmol/l. Recently, Getz et al calculated that in Norway, one of the healthiest nations in the world, about 85% of men and more than 20% of the women over age 40 would be classified as high risk using this criterion.2 If followed, the new recommendations might therefore put most of the Western world's adult population on statin therapy. As the risk to benefit ratio for a more drastic lowering of low density lipoprotein cholesterol is unknown we question the wisdom of this advice.

Are higher statin doses safe?

To achieve this new goal, people at high risk would have to take higher statin doses than currently suggested. This would increase the risk of adverse side effects. In the treating to new targets (TNT) trial, the only study comparing a low and high dose of the same statin, not even 80 mg atorvastatin was able to lower mean low density lipoprotein cholesterol below 1.81 mmol/l.3 Clinical experience has taught us that a dose increase of that size of any drug will inevitably increase both the number and the seriousness of side effects. This apparently did not concern the authors, who concluded, “Intensive lipid lowering therapy with 80 mg of atorvastatin per day in patients with stable CHD [coronary heart disease] provides significant clinical benefit.”

However, overall mortality was not reduced because the smaller number of cardiovascular deaths in the 80 mg atorvastatin …