Cholesterol Drugs and Vitamins Add Up to a Surprise
For: Should You Still Take Vitamin
E?, February 2003
If you have high cholesterol, you may be taking a cholesterol-lowering
drug, such as a "statin"—for example, atorvastatin (Lipitor),
simvastatin (Zocor), or lovastatin (Mevacor). Or you may be taking high-dose
niacin, which raises HDL ("good") cholesterol substantially,
in addition to reducing LDL ("bad") cholesterol, as the statins
do. A few people are now taking niacin plus a statin drug. And they may
be taking antioxidant supplements as well—not only vitamin C and
E, but possibly the trace mineral selenium and others. Indeed, the Wellness
Letter has long recommended vitamin E supplements, along with adequate
intake of vitamin C, for a variety of potential health benefits.
If you are taking any combination of these drugs and supplements,
recent headlines may have you wondering if you are doing the right thing.
In August a study in Arteriosclerosis, Thrombosis, and
Vascular Biology made the surprising finding that supplements of C
and E, selenium, and beta carotene could reduce some of the effects of
cholesterol drugs—specifically the effects of a statin combined with
niacin. The 160 subjects, who had been diagnosed with coronary artery
disease and had low HDL, were divided into four groups. One group took
a statin combined with niacin; a second took a statin, niacin, and antioxidants;
a third took antioxidants alone; and a control group took a placebo. Those
who took the statin and niacin together experienced a dramatic 42% lowering
of LDL and an equally dramatic 26% rise in HDL. Those taking the two drugs
plus antioxidants also lowered their LDL and raised their HDL. However,
the rise in HDL in this group was 40% less. And a certain element of HDL—known
as HDL-2, thought to be the most helpful component in heart health—did
not increase at all in those taking the two drugs and the anti-oxidants.
Those taking antioxidants alone actually experienced a decrease in HDL-2.
The conclusion: Antioxidants seem to "blunt"
some of the good effects of niacin combined with a statin. But the study
had many limitations. One is that it did not investigate the effects of
a statin drug combined with antioxidants, without niacin. In addition,
four antioxidants were given: vitamin C and E (in larger doses than we
advise), selenium, and beta carotene. But there was no way of knowing
which of them blunted the drugs, or if all did.
Then in November a continuation of the same study, published
in the New England Journal of Medicine, analyzed these findings further
by doing detailed studies of the subjects’ coronary arteries. Those
who took a statin plus niacin did best: the blockage in their arteries
shrank somewhat. In those who took the statin plus niacin plus the antioxidants,
blockage increased slightly. They still did better than the two groups
taking only antioxidants or a placebo. Moreover, the niacin/statin group
had the fewest heart attacks. Most notably, only one in 38 of them had
a coronary event, compared with 12 of 38 in the placebo group.
Where this leaves you
What do these studies really prove, if anything? Here are
a few points to keep in mind if you have undesirable cholesterol levels:
• Combining a statin with niacin is a relatively new idea. These new studies do suggest it’s a good way to raise low HDL, lower total cholesterol, and reduce the risk of coronary artery disease.
• If you are taking niacin and a statin, plus antioxidant supplements, talk with your physician about discontinuing the antioxidants. They may be blunting some of the effects of the drugs.
• If you are taking only a statin plus antioxidants, the situation is much less clear. These studies did not address this issue, and there has been little or no other research on it. Moreover, as we’ve said, participants took four antioxidants, making it impossible to identify which had the adverse effect. (We have never recommended selenium supplements, and we withdrew an early recommendation to take beta carotene after this supplement was found to cause harm in some people.) At this point, it’s impossible to know if there are any drawbacks to combining antioxidants with a statin. Talk to your doctor about the potential risks and benefits of antioxidants for you.
• If you are taking only antioxidants, don’t expect them to lower total cholesterol or raise HDL.
Semifinal note: Remember,
all the people in these studies already had coronary artery disease and
low HDL. Do the findings also apply to people with high cholesterol but
not heart disease? It’s hard to say. Still, we do know that lowering
LDL and/or raising HDL reduces the risk of heart disease. And in these
studies the niacin/statin combination lowered the risk dramatically.
Final note: Preliminary findings
from the nearly completed Heart Protection Study, a major English investigation
comparing statins, antioxidants, and their combined effect, show once
again that statins are very effective (niacin was not studied). They also
suggest that antioxidants (vitamins C and E and beta carotene) do not
protect against heart disease, but that they are safe, and apparently
do not interfere with statins. We will keep you informed.
UC Berkeley Wellness Letter, March 2002