High Cholesterol: A Guide to Statins

Your body needs cholesterol to make cells, some hormones, and vitamin D. But too much cholesterol leads to atherosclerosis, which is the medical term for the buildup of sludge (also known as plaque) in your arteries.

Why does this matter? Arteries are the blood vessels that supply nutrients and oxygen to your body. When they get clogged, it reduces blood flow to tissues and organs. This prevents the delivery of vital nutrients and oxygen and can lead to a heart attack or stroke.

Luckily, cholesterol levels can be controlled with dietary and lifestyle changes and by using prescription medications like statins. Here, we’ll cover what you need to know about these common cholesterol medications, including information on how to know which statin is best.

What are statins and what do they do?

Statins are a group of medications that can lower high cholesterol. They work by blocking an enzyme that your body uses to make cholesterol. By blocking this enzyme (called HMG-CoA reductase), statins lower the amount of cholesterol your body makes. This lowers your risk of developing atherosclerosis and atherosclerotic cardiovascular disease (ASCVD). ASCVD is a type of heart disease caused by atherosclerosis that can lead to heart attacks and stroke.

Statins have different effects on various cholesterol and cholesterol-related molecules:

• Lowers LDL cholesterol levels: LDL is the “bad” type of cholesterol and is most closely linked to ASCVD. The lower the better.

• Slightly raises HDL cholesterol: HDL is the “good” type of cholesterol. The higher the better.

• Lowers triglyceride levels: Triglycerides are a type of fat that your body makes from the foods you eat. High triglycerides are linked to a greater risk of heart disease. The lower the better.

Lowering LDL is the main way that statins lower the risk of cardiovascular disease. But statins also work by lowering inflammation in your arteries.

What are the names of some statins?

Statins are commonly prescribed medications. The names of statins available in the U.S. include:

• Atorvastatin (Lipitor)

• Fluvastatin

• Lovastatin

• Pravastatin (Pravachol)

• Rosuvastatin (Crestor)

• Simvastatin (Zocor)

• Pitavastatin (Livalo)

What is high cholesterol?

When you have high cholesterol (hypercholesterolemia), it increases your risk of ASCVD and other health problems. If you have ASCVD, your coronary arteries, which bring nourishment to the heart, may be blocked. This can lead to heart attacks, heart failure, and chest pain (angina). And if the arteries in the neck (carotid arteries) are blocked, it can cause stroke, mini-stroke (transient ischemic attack), or vascular dementia.

High cholesterol can also cause atherosclerosis in other parts of the body, including the legs, kidneys, and aorta (the largest artery in the abdomen). These types of atherosclerosis can cause pain, kidney problems, and even internal bleeding.

Luckily, cholesterol levels can be controlled with dietary and lifestyle changes, as well as with statins. Lowering cholesterol is especially important for people who:

• Have very high cholesterol levels

• Have a history of cardiovascular disease, such as a prior heart attack or stroke

• Have risk factors for cardiovascular disease, such as diabetes, high blood pressure, and smoking

Who should take a statin?

When deciding whether you need a statin, your healthcare provider will look at more than your LDL levels. There are also other risk factors for cardiovascular disease to keep in mind.

According to the 2018 guidelines from the American College of Cardiology and American Heart Association, several groups of people should be taking a statin. We’ll talk about four of these groups below. But there are also people outside these groups who may benefit from taking a statin. 

Even if you don’t fall into one of the categories discussed below, you may need a statin if you’re at high risk for ASCVD. Information such as your age, sex, and health habits can be used to estimate your risk of developing ASCVD. Existing medical conditions are also taken into consideration. Talk with your healthcare provider about your individual risk level. They can help you decide if a statin is necessary. Statins are more likely to help people with high risk than those with low risk.

Keep in mind: If you're over 75 years old, it's not clear if you'll get the same benefits from taking a statin, partly because you may also be at higher risk for side effects.

1. People with existing ASCVD

This includes people who have a history of:

• Angina (chest pain) due to plaque in the coronary arteries

• Heart attack or other conditions related to coronary artery blockage 

• Stroke or mini-stroke

• Peripheral artery disease

• Aortic aneurysm (a bulge in the aorta)

• Revascularization surgery (a procedure that restores blood flow to the heart or other arteries)

In this group of people, the goal of using statins is to prevent further problems in the future.

2. People aged 40 to 75 with diabetes

Diabetes raises your risk of cardiovascular disease. If you have diabetes, it’s important to address risk factors for cardiovascular disease. This includes controlling your blood sugar and blood pressure, quitting smoking, and lowering your cholesterol.

3. Anyone whose LDL is 190 mg/dL or higher

Regardless of your age, and even if you don’t have existing ASCVD or diabetes, a statin is recommended if your LDL is this high.

4. People with familial hypercholesterolemia

This inherited condition affects 1 in 250 people. It causes extremely high cholesterol levels, even in childhood. Without treatment, people with familial hypercholesterolemia are at risk for heart attacks or angina as early as their 20s.

Which statin is best?

Unfortunately, there isn’t a clear answer to this question. It depends on how you define “best.” There’s no evidence to date that proves one statin is the “best” at preventing cardiovascular disease. In addition, statins are available in a wide range of doses. In general, high doses will lower LDL cholesterol more than low doses.

Still, some statins are more potent than others. This means that at equal doses, some statins will lower LDL more than others. Based on their potency and their dose, statins can be categorized as high, moderate, and low intensity. You’ll notice that not all statins come in high-intensity doses, and some don’t come in low-intensity doses.

Rosuvastatin and atorvastatin may lower LDL cholesterol the most

Certain doses of rosuvastatin and atorvastatin reduce LDL more than other statins. Here’s the evidence backing this:

• A 6-week clinical trial comparing rosuvastatin with atorvastatin, pravastatin, and simvastatin found that it lowered total cholesterol significantly more than the others and lowered triglycerides significantly more than simvastatin and pravastatin.

• A 54-week clinical trial compared atorvastatin with fluvastatin, lovastatin, and simvastatin and found that atorvastatin was better at lowering LDL cholesterol than the other medications.

• A systematic review of 75 clinical trials found that rosuvastatin and atorvastatin were the only statins that lowered LDL cholesterol by more than 40% (hence, they’re the only “high-intensity” statins).

Keep in mind: Rosuvastatin and atorvastatin lower LDL the most, but this doesn’t mean they’re the “best” at preventing ASCVD, including repeat heart attack. To date, there has been no clinical trial that directly compares all of the available types of statins in a head-to-head fashion. But for some people who would benefit from significantly lowering LDL, rosuvastatin and atorvastatin may be a good option.

So, what’s the verdict?

The 2018 guidelines from the American College of Cardiology and American Heart Association don’t favor any specific type of statin over another. Instead, the guidelines recommend that people at very high risk for cardiovascular disease should take a high-intensity statin dose rather than a moderate- or low-intensity statin.

How should you take statins?

Your body makes cholesterol at night. Short-acting statins like simvastatin and the immediate-release formulations of fluvastatin and lovastatin should be taken in the evening. Other statins can be taken at any time.

Possible drug interactions

Statins can interact with other medications, including:

• Gemfibrozil (Lopid)

• Amlodipine (Norvasc), in the case of simvastatin

• Digoxin (Lanoxin)

• Cyclosporine (Sandimmune)

• Tacrolimus (Prograf)

• Everolimus (Afinitor)

• Sirolimus (Rapamune)

Talk to your healthcare provider about potential drug interactions so they can determine whether changes need to be made to either your statin or other medications you’re taking. For more information on individual statin interactions, check out our other articles:

• Rosuvastatin interactions

• Atorvastatin interactions

Can you have grapefruit juice when taking a statin?

Grapefruit interferes with how your body processes some statins. This can cause certain statins to hang around in your body at higher levels and for longer periods than usual. The statins affected by grapefruit include atorvastatin, simvastatin, and lovastatin. But the other types of statins, like rosuvastatin, aren’t known to be affected.

While some statin levels may increase if you drink grapefruit juice, it’s not clear how dangerous this is. For example, this study showed that drinking 10 ounces of 100% grapefruit juice every day did raise atorvastatin levels. But it didn’t lead to side effects in the muscles or liver.

The specific amount of grapefruit juice that's considered “risky” varies depending on the person and the situation. And experts don’t always agree on how much grapefruit juice is safe to have with statins. So talk to your healthcare provider if consuming grapefruit is important to you and you’re taking a statin. They can help you decide how much, if any, is safe.

What about drinking alcohol?

For people who don’t have liver disease, it’s generally safe to drink alcohol in small amounts when taking a statin. However, experts recommend avoiding alcohol if you take a statin and have chronic liver problems.

What side effects do statins cause?

Because statins are prescribed to so many people, statin side effects are well known and continue to be studied. The most commonly discussed statin side effect is muscle pain and weakness.

According to studies, people taking statins report muscle pain or weakness much more frequently than those who don’t. But these muscle pains aren’t necessarily caused by a statin.

To get a better idea of whether your statin is the culprit behind muscle pain, ask your healthcare provider whether you should try cycling on and off the statin. For example, you could stop the statin for a month and see if the pain goes away. Then start the statin again to see if it comes back. 

Other statin side effects are covered in-depth in another GoodRx article.

Is it safe to stop taking your statin?

People sometimes want to stop taking statins because they:

• Experience side effects

• Worry about future side effects

• Feel uncertain about the benefit of statins

But the evidence is quite clear. If you need the statin and you stop taking it, you can develop serious health risks. For example, one study followed people who’d had an ischemic stroke (a blood clot blocking an artery in the brain). The participants were prescribed a statin to prevent another stroke from happening. Those who stopped taking their statin had a higher risk of dying or having another stroke than those who continued their statin.

If you’re struggling to take your statin regularly, talk to your healthcare provider about the source of the problem and what you can do to make things easier for you. 

Why trust our experts?

Written by:

Kevin Hwang, MD, MPH

Kevin Hwang, MD, MPH is an internal medicine physician, primary care provider and associate professor at UTHealth McGovern Medical School in Houston, Texas. He teaches residents and students, conducts research and quality improvement projects, and serves as medical director of the UT Physicians General Internal Medicine Center.

Edited by:

Amy B. Gragnolati, PharmD, BCPS

Amy Gragnolati, PharmD, BCPS, is a pharmacy editor for GoodRx. Amy currently holds her pharmacist license in Georgia and California.

Reviewed by:

Patricia Pinto-Garcia, MD, MPH

Patricia Pinto-Garcia, MD, MPH, is a medical editor at GoodRx. She is a licensed, board-certified pediatrician with more than a decade of experience in academic medicine.

Our editorial standards

Meet our experts