Arsonists and Firefighters: The Perpetual Inflammatory Civil War for Survival
A major pharmaceutical success story of the late 20th century was the introduction of statins into clinical medicine. This class of drugs (the firefighters) has contributed to reduced morbidity and mortality from atherosclerotic cardiovascular disease by lowering total cholesterol levels, particularly LDL cholesterol (the arsonists), and also by raising HDL cholesterol levels, albeit less dramatically1. Triglyceride levels may also be reduced. The success of this approach in older adults has also led to the controversial proposal to begin statin therapy even earlier in younger individuals with elevated lipid levels2. Other benefits have also been attributed to statins, including effects on inflammatory and immune responses after myocardial infarction3. Despite this success story, statins are not a panacea. Some patients suffer adverse reactions such as myositis that preclude their taking optimal doses and in some instances prevent statin use altogether. Much less commonly, statins can lead to rhabdomyolysis, especially in combination with drugs such as gemfibrozil4. More recently, the FDA mandated a change in labelling which warns consumers that statins can lead to poorer control of blood glucose levels in patients with type 2 diabetes5. Alternative approaches to the treatment of elevated cholesterol levels, for example therapy with niacin or drugs that influence cholesterol metabolism such as ezetimibe, have either failed in randomized clinical trials6 or fallen out of favor because of relatively weak strength of evidence7.
- Received March 28, 2014.
- Revision received April 3, 2014.
- Accepted April 3, 2014.