Can a patient discontinue a statin (HMG‑CoA reductase inhibitor) if the lipid panel shows normal cholesterol?

No—Statins Should Not Be Stopped Simply Because Cholesterol Is Normal

Statins are prescribed based on cardiovascular risk and disease status, not cholesterol targets alone, and discontinuing them when cholesterol normalizes will eliminate their protective benefit and increase cardiovascular events and mortality. 1

Why Normal Cholesterol Does Not Justify Stopping Statins

The fundamental principle is that statins work by reducing cardiovascular events through cholesterol lowering, and stopping them allows cholesterol to rise back to baseline levels, removing the protection they provide. 1

In Secondary Prevention (Established Heart Disease)

Statins must never be discontinued in patients with established atherosclerotic cardiovascular disease—including those with prior myocardial infarction, stroke, TIA, coronary revascularization, or peripheral arterial disease—except for severe intolerance or end-of-life care. 1

• Discontinuation in these patients leads to more than two-fold increased cardiovascular events, four-fold increased stroke risk, and nearly four-fold increased mortality. 1
• Even brief interruptions of statin therapy are associated with worse outcomes than continuous use. 2, 3
• The American College of Cardiology and European Society of Cardiology both provide the strongest recommendations (Class I) against discontinuation in secondary prevention, regardless of achieved cholesterol levels. 4, 1

In Primary Prevention (No Prior Cardiovascular Events)

For patients without established cardiovascular disease who were started on statins for primary prevention, continuation is generally recommended because:

• The benefit of statins is proportional to both the absolute cardiovascular risk and the magnitude of LDL cholesterol reduction achieved, which depends on the baseline cholesterol level. 5
• Stopping therapy eliminates the ongoing risk reduction, and cholesterol will return toward pretreatment levels. 1
• For adults aged 65-75 years on primary prevention, evidence supports continuing statins as this age group derives clear benefit. 1

The Only Valid Reasons to Consider Stopping Statins

1. Severe Adverse Effects

• Immediate discontinuation is required for severe muscle symptoms suggestive of rhabdomyolysis, CK >10× upper limit of normal with muscle symptoms, or clinical suspicion of rhabdomyolysis. 1, 6
• For mild-to-moderate muscle symptoms, temporary discontinuation with rechallenge at lower dose or alternative statin is the preferred approach rather than permanent cessation. 6

2. Advanced Age with Limited Life Expectancy

• In adults ≥75 years with functional decline, multimorbidity, frailty, or life expectancy <3 years, discontinuation may be reasonable because the time-to-benefit for statins (typically 2-3 years) exceeds remaining lifespan. 1
• However, even in elderly patients with established cardiovascular disease and good functional status, statins should be continued. 1, 6
• For primary prevention in adults >85 years, discontinuation is reasonable in most cases given extremely limited evidence for benefit. 1

3. Pregnancy Planning

• Statins must be stopped 1-2 months before contemplating pregnancy. 4

Common Pitfalls to Avoid

Do not use "normal" cholesterol levels as a reason to stop statins. The cholesterol is normal because the statin is working—stopping it will cause levels to rise again. 1

Do not permanently discontinue without establishing true causality for reported side effects. Many muscle symptoms attributed to statins are actually due to nocebo effect, with randomized trials showing <1% difference in muscle symptoms between statin and placebo groups. 7

Do not stop statins perioperatively unless oral intake is impossible; continuation throughout the perioperative period is recommended to avoid rebound lipid elevations and increased cardiovascular risk. 6

Alternative Management Strategies

If side effects occur, consider these options before complete discontinuation: 1, 6

• Dose reduction to maintain some lipid control while minimizing side effects
• Switch to an alternative statin with lower myopathy risk (pitavastatin, fluvastatin, or pravastatin)
• Add ezetimibe to allow lower statin dosing while maintaining lipid control
• Alternate-day dosing for long-half-life statins like rosuvastatin or atorvastatin

Monitoring After Any Decision

• Reassess lipid panel 4-12 weeks after any dose change or discontinuation. 8
• Continue annual lipid monitoring once stable. 8
• Evaluate muscle symptoms at 6-12 weeks after therapy modifications. 6

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