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Opening the consultation
Explain the purpose of the consultation: “Today we will discuss a type of medication called a statin.”
It is important to establish a good rapport and an open line of communication with the patient early in the consultation: “If you have any questions at any point, or if something is not clear, please feel free to interrupt and ask me.”
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to ask questions
Patient’s ideas, concerns and expectations
Counselling involves exploring a patient’s ideas, concerns and expectations (ICE)...
Ideas
“Have you heard of statins?”
“Do you know anything about statins?”
“Do you know what statins are used for?”
Concerns
“Is there anything about taking statins that worries you?”
Expectations
“Was there anything, in particular, you’d hoped we would discuss today?”
“What would need to happen for you to feel today’s consultation was a success?”
“What do you hope statins might be able to do for you?”
Patient history
It is a good idea to gather a quick, focused history early in the consultation.
Statins are commonly prescribed for adults who have been identified as at risk for cardiovascular disease (CVD) (primary prevention), or for those who have known CVD, such as those who have previously had a heart attack or stroke (secondary prevention).1 Knowing why they have been started on the medication can assist you in explaining why it is important they take it.
It is also helpful to screen for CVD risk factors, including smoking, alcohol, hypertension, and having a sedentary lifestyle. Taking a social history can help you in signposting the patient to any relevant lifestyle advice later in the consultation (e.g. discussing smoking cessation if they are a smoker).
QRISK
In primary care settings, the QRISK assessment tool forms an important part of the NHS health check and is used to estimate a patient’s 10-year risk of developing CVD over the age of 40.
In England, clinicians are advised to use a 10% threshold to guide decision making around the commencement of statin therapy for the primary prevention of CVD.
According to current NICE guidance, people found to have a risk of 10% and above should be offered lipid modification therapy (e.g. atorvastatin 20mg) in addition to lifestyle modification advice.2
Example
“A 10% estimated QRISK score means you have a 1 in 10 chance of developing cardiovascular disease, such as myocardial infarction, stroke or angina, over the next 10 years. Whilst it cannot precisely predict what will happen, it does give us an opportunity to discuss your individual risks and actively look to reduce them, for example by starting a statin.”
Those below the 10% threshold may have a lower 10-year risk of developing CVD, however, opportunities should not be missed to further reduce this risk. For example, lifestyle modification and optimisation of comorbidity management, as well as follow-up QRISK re-assessments every 5 years.
What are statins and how do they work?
Statins are a group of lipid-lowering drugs used to reduce the risk of atherosclerosis and related CVD events.
Statins work by inhibiting a key enzyme in the liver, HMG-CoA reductase, causing a decrease in hepatic synthesis of cholesterol. This, in turn, increases the expression of hepatic cholesterol receptors, increasing uptake of low-density lipoprotein (LDL) from the blood to the liver, resulting in a fall in plasma cholesterol.3
Ensure you use patient-friendly language when explaining this.
Example
“Cholesterol is essential for life as it is used in many processes within the body. However, too much of the ‘wrong sort’ of cholesterol can increase the risk of potentially fatal cardiovascular events such as heart attack or stroke.”
“Statins work by limiting the production of new cholesterol within the body, as well as clearing ‘bad cholesterol’ from the blood. This aims to reduce the total amount of bad cholesterol circulating in the body and, in doing so, reduces the likelihood of future heart attacks or strokes.”
Statins are most effective at reducing LDL-cholesterol concentrations in the body, but not as effective at reducing triglyceride concentrations. Therefore, patients with concerning triglyceride levels may be prescribed a fibrate in addition to a statin, even if the LDL concentration has been adequately lowered.4
How to take statins
Statins are prescribed in the form of tablets and there are several types. Atorvastatin is the most commonly prescribed statin, other common statins include simvastatin and rosuvastatin.1
Statins are usually taken as a once-daily dose. Simvastatin and pravastatin should both be taken at night, whereas atorvastatin and rosuvastatin can be taken at any time in the day; although, ideally, the timing of the statin dose should remain consistent throughout treatment.
If the patient misses a tablet, they should take it as soon as they remember. They should not take two tablets in one day.
Monitoring
Prior to starting treatment, the patient should have a blood test to obtain pre-treatment cholesterol levels, as well as to check liver function. They should then expect to have another blood test within three months of starting treatment and again at 12 months to monitor the effectiveness of the statin.
Explain to the patient that while they will not feel the beneficial effects of the medication, it is important that they continue taking the treatment consistently for maximum therapeutic benefit. Pitching information at the right level for the patient, as well as addressing their concerns, will also improve the likelihood of them adhering to the treatment regimen.
Side effects
The main side effect to mention for statins is unexpected muscle pain, tenderness, cramps or weakness. Myalgia is known to be commonly reported in those taking statins and is not usually a cause for concern.
However, rarely, muscle toxicity can be a severe side-effect of statins, therefore, you should advise the patient to report any such symptoms to their GP promptly.5
Additionally, statins can very rarely cause interstitial lung disease. Patient should be informed to seek advice if they develop a cough, shortness of breath or weight loss.
More common side effects of statins include nausea, constipation, diarrhoea, flatulence and headache.
Generally, statins are well-tolerated and their long-term safety is well proven. It is important to reassure patients of this as negative media coverage is known to negatively influence treatment persistence, which is associated with increased risk of CVD mortality.3,6,7
Key interactions
There are some interactions with foods and other medicines that patients taking statins should be aware of.
For example, grapefruit can interfere with the effectiveness of certain statins (e.g. simvastatin), so the patient should be aware if this applies to their medication. Similarly, other medicines, including some antibiotics, immunosuppressants and fibrates can affect statin treatment and potentiate side effects.
You should advise the patient to refer to their patient information leaflet for guidance and discuss any new medication or supplements with their GP or pharmacist.
Lifestyle advice
Statins work to reduce the risk of cardiovascular events in an individual in addition to a healthy lifestyle. You should stress to the patient the importance of regular physical activity, choosing healthy foods, cutting out smoking and limiting alcohol intake in helping to improve their cardiovascular health.
Explain that they should be aiming to exercise regularly. Ideally, this should be a physical activity of moderate intensity for a minimum of 30 minutes, at least five days a week. However, what the patient is able to do will depend on their physical health and mobility and so reasonable adjustments should be suggested to the patient as even a little is better than none at all.8
A healthy diet can benefit in many ways, including weight loss, mood-boosting, and preventing serious health conditions such as type 2 diabetes and heart disease. Advise the patient to eat a balanced diet with fruits, vegetables and starchy foods providing the bulk of most meals. Limiting intake of foods and drinks high in fat and sugar and swapping saturated for unsaturated fats can be cardioprotective. Regular servings of oily fish, whole grains, and nuts and seeds are also positive additions to the diet.1,9
If the patient is a smoker, you should explain that smoking is a risk factor for atherosclerosis and provide further details about local smoking cessation services.
Example
“There are ways you can improve your heart and blood vessel health alongside taking statins. Regular physical exercise can help maintain a healthy weight, improve sleep and manage stress, as well as reduce your chance of developing conditions such as type 2 diabetes, cardiovascular disease and joint and back pain. Activities that increase your heart rate, such as walking, cycling and playing sports, are the most beneficial forms of exercise for heart health and the more you do the healthier your heart will become.”
“A balanced diet can also benefit your health in a number of ways: positive easy changes include eating plenty of fruit and vegetables, eating unsaturated rather than saturated fats, choosing wholegrain foods and cutting down alcohol consumption. Have a look online for lots of ideas and resources about heart-friendly activities and foods.”
Closing the consultation
It is good practice to summarise the key points at the end of the consultation to check the patient’s understanding and address any remaining questions.
You should also provide the patient with a leaflet about statins and general cardiovascular health (or direct them to the relevant NHS web page), so they can read this in their own time.
Make sure to thank the patient for their time at the end of the consultation.
Example
“To summarise, statin medication will help to lower your cholesterol and reduce the risk of cardiovascular events, such as heart attack or stroke, so long as you take it regularly. You’ll need to take the medication at the same time each day and be aware of any food or other medicines that may affect your statin treatment. If you are unsure about how any new medicines may affect your statin therapy, it is best to check for any special instructions with your doctor or pharmacist. You should also seek urgent medical advice if you have any concerning symptoms, like those we have discussed.”
“Alongside your statin medication, stopping smoking, eating well and exercising can help to cut your risk of cardiovascular disease as well as improve your overall health and wellbeing. I appreciate that I have given you a lot of information for one consultation, so I am also giving you a leaflet to take home that summarises the key points.”
“Are you happy with everything we have discussed and do you have any questions for me?”
References
National Institute for Health and Care Excellence. Cardiovascular disease: risk assessment and reduction, including lipid modification. Updated September 2016. Available from: [LINK]
National Institute for Health and Care Excellence. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. 2016. Available from: [LINK]
Tidy, C. Statins and other Lipid-lowering Medicines. Edited August 2017. Available from: [LINK]
British National Formulary. Dyslipidaemias. 2020. Available from: [LINK]
Medicines and Healthcare products Regulatory Agency. Statins: benefits and risks. December 2014. Available from: [LINK]
National Institute of Health and Care Excellence. Our stance on: Statins. [no date]. Available from: [LINK]
Nielson SF, Nordestgaard BG. Negative statin-related news stories decrease statin persistence and increase myocardial infarction and cardiovascular mortality: a nationwide prospective cohort study. Eur Heart J. 2016 Mar 14; 37(11): 908-16. Available from: [LINK]
UK Chief Medical Officer. Physical activity for adults and older adults. 2019. Available from: [LINK]
Public Health England. The Eatwell Guide. September 2018. Available from: [LINK]
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