After learning that his bad cholesterol was twice the recommended limit, my 38-year-old patient was concerned about developing heart disease early in life, like his father and grandfather.
Though he changed his diet and walked for exercise, his level of artery-blocking bad cholesterol was 220 and his total cholesterol was 284. Normal total cholesterol is below 200 and bad, or LDL, cholesterol should be less than 100.
He found out about his cholesterol risk from blood taken for a life insurance physical. The results led him to contemplate his own mortality. Heart disease is the No. 1 killer of adults and stroke is third.
My patient lost about 15 pounds and his wife changed the family diet, but even after three months his cholesterol was still too high. It's likely that he has an inherited cholesterol problem. His brother thinks red rice yeast extract, an over-the-counter herbal medication, has helped lower his cholesterol to normal levels. It hasn't helped my patient much though.
Despite his relatively young age, he came to me wanting to start prescription cholesterol medication. A few years ago that would have been almost unheard of. With direct-to-consumer ads now commonplace, my patients know many of these drugs by name, along with some of their potential side effects.
Choosing a cholesterol drug boils down to three questions: Will it get the cholesterol low enough, will the patient tolerate it and can the patient afford it?
I target LDL cholesterol for reduction to 100 or less. With heart-disease patients and diabetics, I try to get the LDL cholesterol down to 70. It's tough to do that with diet, exercise and older generic cholesterol medications, but the science shows it's worth it.
New drugs and combinations make it easier to hit more aggressive cholesterol goals. Reductions of 100 points or more are now possible. Vytorin, a combination of Zetia and Zocor, is what I chose for him. Combining Zetia, which blocks cholesterol from entering the bloodstream, with a generic or a brand-name statin , such as Crestor or Lipitor, works well, too.
Many of my patients have moderately high cholesterol levels between 200 and 240. A minority of them will lose weight, change their diet and exercise to control it. Coronary artery disease will eventually catch up to many.
One 55-year-old patient dropped 56 pounds to 179 pounds and came off his cholesterol and blood pressure medications following a vegan diet that I prescribed. He is the exception. Most patients have good intentions of managing their health without medication, but can't sustain the improvements long term.
Generic cholesterol medications such as lovastatin, pravastatin and simvistatin have come on the market in recent years. I choose them when I aim for a moderate cholesterol reduction of up to 40 points. Sometimes insurers push generics so much that we sacrifice some control of cholesterol with more potent brand-name drugs to find a medication the patient can afford.
Finding the right medication or combination of medications is half the battle. Keeping the patients on the medication long enough to do them any good is the other half. Many patients stop their cholesterol meds within the first six months.
The most common side effect from cholesterol medications that I see is muscle aches that stop when the medication is halted. Thankfully, I've never had a patient with a severe reaction to cholesterol medication, but I've seen many patients who couldn't tolerate statin therapy.
Some patients blame every arthritic ache and pain in their body on their cholesterol medication and look for any excuse to stop it. Sometimes we cut the medication down to every other day and they are able to get by. These medications really are lifesavers for many, and I try hard to keep patients interested in keeping their cholesterol low.
I've tried nearly every prescription cholesterol medication there is for one man with diabetes and high blood pressure. He's taking an over-the-counter pill called CholestOff now. His cholesterol came down to 233 from 303, and that's about the best I've been able to do for him. If he improved his diet and exercised, he wouldn't have to rely so much on the medicine.
About 40% of adult patients in my practice have had their cholesterol measured in the last five years. More of them should. Cholesterol screening is an area we're working on improving.
Our computerized patient database gives us some tools to help those who have stopped refilling their drugs or the ones I've missed prescribing for. Of our high-risk patients with coronary artery disease, I know all but 19 are refilling their cholesterol lowering therapy. Twelve of those patients are over 80. The other seven are in the process of being followed up on.
Deciding when to stop cholesterol lowering therapy is an issue with elderly patients. Although they don't like taking the extra pills, cholesterol-lowering therapy for patients over 80 cuts their risk of dying over the next three years substantially.
My patient in his 30s is getting along well with his medication so far. With any luck, he'll be in the normal cholesterol range shortly and live many healthy years
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