Can a patient with normal cholesterol levels stop taking statins (HMG-CoA reductase inhibitors)?

No, Patients Should Not Stop Statins When Cholesterol Levels Normalize

Statins should be continued indefinitely regardless of achieving normal cholesterol levels, as their cardiovascular protective benefits extend far beyond cholesterol lowering and discontinuation significantly increases the risk of cardiovascular events, stroke, and death. 1

Why Statins Must Be Continued Despite Normal Cholesterol

Statins Work Beyond Cholesterol Reduction

• Statin therapy provides cardiovascular protection through multiple mechanisms independent of cholesterol lowering, including anti-inflammatory and antithrombotic effects that reduce atherosclerotic cardiovascular disease (ASCVD) risk 1
• The European Society of Cardiology emphasizes that statin therapy should be guided by the patient's cardiovascular risk level, not solely by cholesterol numbers, as statins provide benefits even when cholesterol is in the "normal" range 1
• Discontinuing statins simply because cholesterol targets have been achieved fundamentally misunderstands the mechanism of benefit and exposes patients to substantially increased cardiovascular risk 1

Severe Consequences of Statin Discontinuation

• Statin discontinuation is associated with more than two-fold increased rate of cardiovascular events, more than four times increased risk of stroke, and almost four-fold increased risk of death in patients with stable coronary heart disease 1
• In patients with acute coronary syndromes, withdrawal of statin therapy after admission completely abrogates the beneficial effect and increases cardiac risk compared with patients who continue statins 2
• Discontinuation of statins after onset of symptoms is associated with increased event rates during the first week, independent of cholesterol levels 2

Current Guideline Recommendations on Statin Continuation

Primary and Secondary Prevention Populations

• In adults 40 to 75 years of age with diabetes mellitus, moderate-intensity statin therapy is indicated regardless of estimated 10-year ASCVD risk 3
• For intermediate-risk adults (≥7.5% to <20% 10-year ASCVD risk), LDL-C levels should be reduced by 30% or more, and for optimal ASCVD risk reduction in high-risk patients (≥20%), levels should be reduced by 50% or more 3
• In patients with LDL-C ≥190 mg/dL, maximally tolerated statin therapy is recommended 3

Monitoring Rather Than Discontinuation

• Adherence to changes in lifestyle and effects of LDL-C-lowering medication should be assessed by measurement of fasting lipids 4 to 12 weeks after statin initiation or dose adjustment and every 3 to 12 months thereafter 3
• The American College of Cardiology recommends against reducing statin dosage after target achievement, as evidence shows this leads to loss of cholesterol control in most patients 1
• At 6 months, nearly 50% of primary prevention patients have already stopped therapy, with the most common pattern of non-adherence occurring at 1 month when target levels are reached—this represents a critical pitfall to avoid 1

Limited Exceptions to Continued Statin Therapy

Age-Related Considerations

• In adults 75 years of age or older, it may be reasonable to stop statin therapy when functional decline, multimorbidity, frailty, or reduced life expectancy limits the potential benefits 3
• However, initiating a moderate-intensity statin may still be reasonable in adults ≥75 years with LDL-C 70 to 189 mg/dL 3

True Statin Intolerance

• If unexplained severe muscle symptoms or fatigue develop during statin therapy, promptly discontinue the statin and evaluate for rhabdomyolysis by checking CK, creatinine, and urinalysis for myoglobinuria 3
• True statin intolerance is rare but represents a valid reason for discontinuation and should be evaluated promptly 1
• However, even with documented statin intolerance, the goal is to find an alternative statin regimen or dosing strategy rather than complete discontinuation 3

Management of Patients Who Achieve Target Cholesterol

Continue Current Therapy

• When LDL-C goals are achieved on standard doses of statins, physicians should continue the effective regimen rather than discontinue or reduce dosing 1
• For patients at very high risk who achieve LDL-C <100 mg/dL on standard doses, intensifying therapy to achieve <70 mg/dL may be considered, but discontinuation is never appropriate 3

Address Non-Adherence Proactively

• Non-adherence to statin therapy is the most important modifiable factor that compromises treatment outcomes 1
• Pseudo-resistance due to nonadherence or non-persistence in real-life circumstances is probably the main cause of insufficient LDL-C response to statin treatment 4
• Clinicians should proactively counsel patients that achieving normal cholesterol is evidence the statin is working and must be continued to maintain cardiovascular protection 1

Critical Clinical Pitfalls to Avoid

• Never discontinue statins based solely on achieving cholesterol targets—this represents a fundamental misunderstanding of statin pharmacology 1
• Avoid unnecessary discontinuation by obtaining a history of prior or current muscle symptoms to establish a baseline before statin initiation 3
• Do not reduce statin dosage after achieving targets, as most patients will lose cholesterol control 1
• Recognize that the largest increases in LDL-C occur in patients who discontinue high-intensity statins (35.6% increase), with the lowest proportion achieving LDL-C <100 mg/dL among those who stop therapy 5