Should I avoid statins (HMG-CoA reductase inhibitors) with diverticulitis?

Statins and Diverticulitis: Medication Management

There is no need to avoid statins in patients with diverticulitis, as there is no evidence that statins increase the risk of diverticulitis or worsen its outcomes. 1, 2, 3, 4

Evidence on Statins and Diverticulitis

The American Gastroenterological Association (AGA) guidelines do not specifically address statins in the management of diverticulitis, suggesting there is no significant concern about their use in this patient population 1. Multiple population-based studies have investigated the relationship between statins and diverticulitis with the following findings:

• A 2020 population-based case-control study found that statins were not associated with an increased risk of developing acute diverticulitis requiring hospitalization 2
• Some evidence suggests statins may actually be beneficial in certain populations:
  • A subgroup analysis showed statins might decrease the risk of acute diverticulitis in elderly patients (age >64 years) 2
  • A 2016 study found that current statin use was associated with a reduced risk of emergency surgery for diverticular disease (adjusted OR 0.70 [0.55-0.89]) 3
• A 2021 nested case-control study found no evidence supporting either a protective or harmful effect of statins on the risk of diverticular disease after accounting for diagnostic bias 4

Medications to Consider Avoiding with Diverticulitis

While statins appear safe, the AGA guidelines do recommend avoiding certain medications in patients with diverticulitis:

1. Non-aspirin NSAIDs: The AGA suggests advising patients with a history of diverticulitis to avoid non-aspirin NSAIDs if possible (conditional recommendation, very-low quality evidence) 1

   • Observational studies indicate NSAIDs are associated with a moderately increased risk of diverticulitis episodes and complicated diverticulitis

2. Aspirin: The AGA suggests against routinely advising patients to avoid aspirin (conditional recommendation, very-low quality evidence) 1

   • While there is a slightly increased risk of diverticulitis with aspirin use (RR 1.25,95% CI 0.61-2.10), the cardiovascular benefits often outweigh this risk

Management Recommendations for Diverticulitis

For patients with diverticulitis, the AGA recommends:

• Fiber supplementation: Gradually increasing fiber intake to 25-35 grams daily is recommended for patients with a history of diverticulitis 5
• Physical activity: Vigorous physical activity is suggested for patients with diverticular disease 1, 5
• Dietary considerations: No need to avoid nuts, popcorn, or small-seeded fruits 1, 5
• Medications to avoid if possible: Non-aspirin NSAIDs and opioid analgesics 1, 5

Clinical Pitfalls to Avoid

1. Don't discontinue statins unnecessarily: Stopping statins in patients with appropriate indications (e.g., cardiovascular disease prevention) could increase their risk of cardiovascular events without providing benefit for diverticulitis management

2. Don't overlook medication interactions: While statins themselves don't appear to worsen diverticulitis, be mindful of potential interactions between statins and antibiotics commonly used for diverticulitis (particularly macrolides like clarithromycin, which can increase statin levels)

3. Don't ignore cardiovascular risk: Many patients with diverticulitis are older and have concurrent cardiovascular risk factors requiring statin therapy; maintaining appropriate statin therapy is important for overall mortality and morbidity reduction

4. Don't confuse recommendations: While non-aspirin NSAIDs should be avoided when possible in patients with diverticulitis, this recommendation does not extend to statins

In conclusion, current evidence does not support avoiding statins in patients with diverticulitis. In fact, some evidence suggests statins may be beneficial in reducing complications in certain populations.