Paradigm Shift in Lipid Management - Episode 6
Alan Brown, MD: Keith, I don’t want to cut you off. I’d like to hear your thoughts, and then I’m going to challenge you with 2 questions. No. 1, how do you deal with statin myopathy if people are having adverse effects? Give us a few of your approaches on that. The second question is for everyone. Guidelines originated to avoid us using potentially dangerous and expensive drugs on too many patients. Statins are now very cheap, and we know they’re extremely safe. Instead of deciding who we shouldn’t be treating, should we be thinking about more primary prevention and treating patients earlier in life?
Keith, those are the 2 challenges I’m going to give you. First, how do you deal with statin intolerance? Second, should we be thinking more about early therapy, now that the drugs are cheap and proven to be safe?
Keith C. Ferdinand, MD: To make 1 brief comment about shared decision-making, I agree with Pam and Seth that it is the bedrock of how we approach our patients. It’s not, “Thou shalt do”; it’s “Let’s do this together.” One of the things I often do, especially with patients from racial and ethnic minorities, is try to get the materials. You can get them from some of the major organizations—American Heart Association, American College of Cardiology, CardioSmart, Association of Black Cardiologists. Get the materials, whether they are electronic or printed, that have a big font and a multicultural appearance. Patients like to see patients who look like them.
For those who don’t speak English as their first language, there are materials in Spanish, Chinese, Vietnamese, and different languages. That person might speak English, but they like to see foods and pictures of activities with people who are from their community, race, or ethnicity. One important thing is to have cultural competence when you have health literacy. You have culturally appropriate literacy and level-appropriate materials so that the patient can become a partner in his or her care.
For people who are statin intolerant, we know that in usual clinical practice, they are estimated to be 10% to 15% of patients. In clinical trials, it’s hard to prove the number is that high. In fact, we think it’s quite low. That being said, I will often tell the patient, “OK, you can’t tolerate the medicine, but we have others in that class of medicine. Let’s see what we can do.” We know it’s off-label, but rosuvastatin has been reported to give a benefit when taken 2 to 3 times a week, even at a lower dose, because of its long half-life. The lower dose is clearly more efficacious in patients of Asian descent. It makes sense to use the longer-acting statin that will perhaps be better tolerated. That could be given intermittently.
The lipid hydrophilic vs lipophilic statin story is a bit mixed. There are some data that patients prefer, but it’s hard to tell. Sometimes, you have to move it around. Ezetimibe has a benefit. It can often be added, even to a moderate- or low-dose statin, to give an additional 10% to 15% LDL [low-density lipoprotein] reduction. In some cases, the benefit can be as high as 20%, so I use that. We can’t forget diet. Diet will lower LDL only approximately 6%, but there are some dietary tools: pectin; psyllium, which is the fiber that’s used for constipation; oats. Those are some things that—when added to the conventional diet, which avoids saturated fat—may give additional lowering. I use those tools to empower the patient.
What was your other question, so that I can answer it before I finish?
Alan Brown, MD: Assuming we have an inexpensive and cheap therapy that seems to have excellent safety, should we be thinking about starting everyone on it earlier in life?
Keith C. Ferdinand, MD: My answer is yes. I’m going to tell you why. In medicine, we use the term normal. You look at lab slips, and they’ll have a range. Within that range is normal. But if you look across the globe, Indigenous, Amazonian, Pacific Islander, rural Chinese, and rural African people walk around with LDLs of 30mg/dL and 40mg/dL. In those particular populations, 50mg/dL is probably high. They don’t have the same high burden of atherosclerotic cardiovascular disease.
We’re looking at the average when we see the people with the LDLs of 115 to 120 mg/dL. But average is not normal. I’m from New Orleans. We have a lot of crime, unfortunately. On any given weekend, 2 to 4 people will be shot and killed. In some big cities like Los Angeles, Chicago, or New York, it may be 8 or 10 people. That’s the average. That’s not normal.
Alan Brown, MD: Pam, any thoughts on the patient’s love for coenzyme Q10?
Seth J. Baum, MD: I was just going to say that, Alan.
Pamela Bowe Morris, MD: Seth, I’ll let you take it away.
Seth J. Baum, MD: I was going to say that we can’t forget coenzyme Q10, because so many patients believe in it. I recommend it. If a patient has a problem, I put the patient on 100 mg per day of coenzyme Q10. In some patients, it works, and that’s great. Then you have another patient who’s taking a statin. I see no downside, and I do it.
Alan Brown, MD: Yes. Even though the data are questionable on whether it does anything, I do the same if the patient can afford it. It’s not cheap. I don’t proscribe it. If someone takes it and thinks they feel better, that’s fine. It’s similar to vitamin D. We had a little observational trial that didn’t seem to be reproducible, showing that replacing the vitamin D might reduce the statin adverse effects. If a patient wants to do it, that’s fine. I feel the same about coenzyme Q10. I have no desire to tell someone who’s feeling better to stop it.
Hypothyroidism is the 1 thing that I’m strict about. If a patient is having statin myopathy and they have hypothyroidism, I make sure they’re euthyroid, because that definitely can exacerbate the muscles.
Matt, do you have any other thoughts? Is there something we didn’t cover?
Matthew J. Budoff, MD: There may be some data that vitamin D deficiency exacerbates things. I want to remind people to check their vitamin D levels in places where we wear long sleeves and cover up way too much, compared with what we were expected to do when we were created. Most of us are walking around with vitamin D deficiency, and that might exacerbate statin myalgias.
Seth J. Baum, MD: To continue on the vitamin D theme, we have to identify the optimal vitamin D level. That is the other question, because when we supplement a patient’s vitamin D, the patient wants to know what level is desirable. I did a very substantial literature search on this, and the best study that I found was an observational study, but it had 750,000 people in it. It’s old, and it was from Israel through their national health care system. The optimal level is in the upper 30 ng/mL range. I tell patients 30 to 40 ng/mL. I don’t like to see it higher because there are dental downsides.
Transcript Edited for Clarity