Statins are the most prescribed drugs in the world for lowering cholesterol. If your ApoB or LDL-C is high and diet and training haven't fixed it, this is the default next step.

Within a few weeks your LDL and ApoB drop 30-55% depending on dose. Atorvastatin (Lipitor) and rosuvastatin (Crestor) are the two most potent options and the ones covered here.

Statins competitively inhibit HMG-CoA reductase which is responsible for the rate at which the liver produces its cholesterol, and you end up pulling more cholesterol out of circulation the blood as a counterforce. In turn lowering LDL-C

Deep-dive

Dosing:

• Atorvastatin: 10-20mg daily is moderate intensity (lowers LDL 30-49%), 40-80mg daily is high intensity (>50% LDL reduction). Start at 20mg for most people, titrate up at 6-8 week intervals based on ApoB/LDL response
• Rosuvastatin: 5-10mg daily is moderate intensity, 20-40mg daily is high intensity. Start at 10mg for most people. Women of East Asian descent should start at 5mg due to higher plasma concentrations at the same dose
• Timing: Both atorvastatin and rosuvastatin have long half-lives (14-20 hours), so they can be taken any time of day, with or without food. Consistency matters more than timing. Shorter half-life statins like simvastatin need to be dosed at night, but not these two
• Choosing between the two: Rosuvastatin is slightly more potent per mg, raises HDL a bit more, doesn't go through CYP3A4 (fewer drug interactions), and is usually the default for anyone on other medications or compounds. Atorvastatin has the longest safety track record, is cheaper, and is better studied in acute coronary syndrome settings. Either is a reasonable first choice
• Women: no female-specific dose adjustment needed outside the East Asian rosuvastatin note above. Do not take either statin during pregnancy or while breastfeeding. If you're trying to conceive, discontinue before attempting
• If muscle symptoms develop: don't stop outright. Options include dropping to alternate-day dosing (rosuvastatin's long half-life makes this viable and it still provides ~70% of the LDL benefit), switching statins (atorvastatin ↔ rosuvastatin), or trying pravastatin or fluvastatin which have less muscle signal. The National Lipid Association recommends multiple strategies before labeling someone "statin intolerant"
• With food interactions: avoid grapefruit juice with atorvastatin (it inhibits CYP3A4 and raises blood levels). Rosuvastatin is unaffected by grapefruit. Avoid taking rosuvastatin within 2 hours of aluminum/magnesium antacids

Here's what you can expect:

LDL-C and ApoB start dropping within the first 1-2 weeks and reach their new steady state by 4-6 weeks. Most people see 30-55% LDL reductions depending on dose and drug, with ApoB falling slightly less proportionally (roughly 40-45% reduction when LDL drops 50%). If your numbers aren't where you want them after 8 weeks, it's either a dose issue, an adherence issue, or you need add-on therapy like ezetimibe.

You won't feel anything. Statins don't produce noticeable subjective effects, there's no energy change, no mood change, no libido change in the vast majority of people. If you feel dramatically different within days of starting, that's almost certainly expectation effect rather than the drug, which is supported by the SAMSON trial data below.

Side effects & risks:

• Muscle aches are the most common reason people quit statins, but most of it isn’t actually the drug. When patients who’d previously stopped statins for side effects were given alternating months of the drug, a placebo, and nothing at all, symptoms were nearly identical on the statin and the placebo, and both were worse than taking nothing. Roughly 90% of what people feel is the act of taking a tablet, not the statin inside it. True pharmacologic muscle pain caused by the drug sits around 0.5% of users. Rhabdomyolysis (the dangerous version) is vanishingly rare. If you get muscle aches on a statin, don’t quit. Drop the dose, switch to the other statin, or try alternate-day dosing before deciding you can’t tolerate it. Most people who “can’t take statins” actually can.