Routine statin prescription and the prevalence of sexual dysfunction | Dr. Adam Tabriz


Embodying the need for a personalized approach for optimal patient compliance and health outcomes

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Disclaimer: This article is written to serve as a source of perspective based on my views and existing scientific evidence. It should never be used as medical advice. My advice is for everyone to consult their doctor to seek out the unparalleled personalized treatment option.

HMG-CoA reductase inhibitors are a class of drugs that have been around for the past three decades. It is known as “statins”, which doctors prescribe to lower blood lipid levels in simple terms. LDL (low density lipoprotein) is a protein-related subcategory of cholesterol. Its reduction by the use of Stain also reduces disease and mortality in people at high risk of cardiovascular disease.

Some of the commonly prescribed statins are:

Atorvastatin (Lipitor),

Fluvastatin (Lescol, Lescol XL),

Lovastatin (Mevacor, Altoprev),

Pravastatin (Pravachol),

Rosuvastatin (Crestor),

Simvastatin (Zocor), et.

Pitavastatin (Livalo).

With minor variance between each member of the statin family, their effects and side effects are generally similar.

Today, statins comprise the most commonly prescribed cholesterol-lowering drugs.

Although statins have a proven track record of prolonging life, they come with specific side effects. This is why it is crucial to personalize treatments with statins to avoid non-adherence or, at the other end of the spectrum, unnecessary prescription and overdose of statins.

One of the few still controversial side effects of statins is their impact on sex hormones!

Based on a report from the Center for Disease Control (CDC), nearly 28% of American men and women over the age of 40 are on some form of statin regimen. Yet only 61% of them continued taking the drug after three months, and only 55% remained on the drug after six months.

Let’s keep in mind that while Statis affects the hormonal component of sexual performance in men. However, according to a study published in the Global Journal of Men’s Health, Statins appear to improve erectile function. Since LDL-C is associated with restoring endothelial function (the single layer of blood vessel tissue of cells), good endothelial function is imperative for erection. The study suggests that statins can improve endothelial function through ‘pleiotropic’ properties, including increased availability of nitric oxide, which is believed to be the essential mediator in penile erection, decreased stress oxidative and antioxidant effects.

Simply put, meanwhile, HMG-CoA reductase is the central enzyme in cholesterol metabolism, and sex hormones such as estrogen and androgen are the byproduct of some form of cholesterol metabolism, one would logically expect androgens to be physiologically inferior. Indeed, statins inhibit the local synthesis of the production of androgen substrate (male hormone). The pleiotropic effects of statins appear to be somewhat similar but unrelated to the physiological effects of lowering testosterone.

A published study in Diabetes Care by the American Diabetes Association in 2009 highlighted the possible correlation between statins and hypoglycemia. According to the publication, the high prevalence of hypogonadism in men with type II diabetes who were also taking statins suggested their potential negative exercise testosterone levels. Some postulate that they do this by reducing the availability of cholesterol for androgen synthesis. The study also noted that although men with type 2 diabetes are likely to have lower testosterone levels, total testosterone levels were significantly lower in men treated with statins.

A 2013 meta-analysis reported in BMC Medicine suggested that statins might, in fact, partially reduce testosterone in the blood.

Endocrinology Advisor suggests total testosterone in men and other factors; DHEA (dehydroepiandrosterone) and SHBG (sex hormone binding globulin) in men and postmenopausal women were all inversely associated with statin use.

Conclusion; Patients receiving statins based on clinical guidelines to lower blood cholesterol and lower total testosterone also have lower levels of sex hormone binding globulin (SHBG) and dehydroepiandrosterone (DHEA). Originally published in The Journal of Clinical Endocrinology & Metabolism, the findings are supported by other studies published in Clinical and translational endocrinology.

Numerous clinical trials focusing on cardiovascular (CV) disease mortality and morbidity have definitively confirmed the indication of the statin as a lipid-lowering agent. But tests done in the past have rarely, if ever, considered personal factors, including gender and hormonal imbalance. Furthermore, it is also postulated that even the statin treatment regimen may differ between men and women.

A study published in Clinical Lipidology suggests a different prescription for these treatments, especially in the dosage between men and women. Thus, requiring the appropriate statin dose for a male sex may be insufficient in women with cardiovascular disease.

It is essential to realize that most guidelines for treating an individual with a statin drug are simply based on the population health model. This means that treatment criteria for lowering blood cholesterol are based solely on similar treatment outcomes in a group of individuals, including the distribution of those outcomes. Therefore, the health outcomes of these groups with statin therapy are the determining factor for public and private sector decision makers. In other words, if treatment with statins prevents a cardiovascular event in 80% of the selected group, then it becomes the standard of practice to prescribe statins to all those who meet the established criteria.

In the population model, people who experience adverse effects from statins will be considered for treatment review. But what if these side effects are associated with subtle but significant symptoms, such as sexual dysfunction, fatigue and loss of energy that at first do not prompt the patient to ask help or can be attributed to another problem?

With increasing patient engagement in reducing the costs of their personal medical care and a value-based reimbursement system for physicians, population health cannot meet these demands. Overall, population health is failing to meet the health care needs of the 21st century. This appears to be the result of increasing the public’s knowledge base and access to information. Additionally, Millennials have the freedom to have individual expectations and be encouraged to be involved in their care, but receive care that is only suitable for the majority and fits a particular profile of social determinants of disease and health.

It is, indeed, time to accept the bitter reality of the health of the retired population.

Population Health has worked reasonably well since its inception in the 1900s. It is inexpensive as long as subjects follow the One-Size-Fits-All model of the program. But in contrast, population health tends to omit the minority crowd and the vulnerable.

The risk-benefit ratio in medical practice is the keystone of clinical judgment, as every physician continually weighs the risks against the benefits of a particular treatment or intervention during clinical evaluation.

Therefore, the clinical decision on the treatment and prescription of statins may vary from patient to patient with the same diagnosis.

Every healthcare professional is concerned with setting realistic expectations with patients regarding the statin treatment protocol. This includes taking into account the patient’s perception, knowledge and priorities and balancing them against the physician’s objective determination. The side effects of statins can nevertheless be severe, satisfying in certain (individual) circumstances. As one of the biggest concerns about sex hormone imbalance, cardiovascular disease can sometimes be more serious than the effects associated with hormone imbalance, even though the long-term consequences of hormone imbalance can be just as harmful.

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