DEAR DR. ROACH: I am a 63-year-old man taking 20 mg of rosuvastatin a day, and my blood showed that my total cholesterol level was 136 mg/dL; my HDL was 47 mg/dL; and my LDL was 70 mg/dL. I was then given 10 mg of ezetimibe, and my LDL reduced to 43 mg/dL. I read that low cholesterol can cause a bleed in the brain, and because the total cholesterol level was below the normal range, I was concerned.
I also developed cramps in my hand, and I stopped taking ezetimibe. To my surprise, the muscle cramps stopped. When I went back to the doctor, I was told that the lower cholesterol levels are, the better. If low cholesterol can cause a brain hemorrhage, how low is too low? Did I do the right thing in stopping ezetimibe? — A.W.
ANSWER: Statin drugs like rosuvastatin reduce the risk of heart attack and overall stroke in people who are at a high risk to develop them. Unfortunately, they have downsides to them as well. It is not low cholesterol that increases the risk for a stroke due to bleeding in the brain (a hemorrhagic stroke); it is the statin. We believe this because a different type of medication, the PCSK9 inhibitors (which are given by injection), does not increase the risk of a hemorrhagic stroke, despite the fact that they lower LDL cholesterol more powerfully than statins.
The overall risk of hemorrhagic stroke in people taking statins (compared to a control group that wasn’t on statins) is low: 0.06%. Compared alongside the expected benefit in reduction of death, heart attack and overall stroke rate, the downside is small for most people who are at an increased risk. Certainly, in a person with a history of a heart attack, a thrombotic stroke or an embolic stroke, the benefit greatly outweighs the risk.
However, in a person with a history of a hemorrhagic stroke who has a greatly increased risk of having another one, statins need much more careful consideration. They may still be the best choice in a person with multiple other risks. A person with a history of hemorrhagic stroke who is at a low risk for heart disease or other strokes should avoid statins. Some people may benefit from a PCSK9 inhibitor, which reduces heart disease risk without increasing hemorrhagic stroke risk.
Finally, ezetimibe works by blocking absorption of cholesterol in the intestine. It has a low risk of muscle aches, but can cause joint aches. I wonder if your hand problem was a joint problem, since most people with muscle aches due to cholesterol medicine notice them in larger muscles like the legs, arms and back.
I don’t have enough information to tell you what the optimal treatment is; though, in hindsight, stopping the ezetimibe, which stopped your side effect, was a smart idea. Only your doctor, who can go over your individual risk for heart disease and stroke based on lots of information I don’t have, can inform you of the relative merits of statins or other treatments to reduce heart disease and stroke risk.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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