winterallsummer Posted February 13, 2014 Share Posted February 13, 2014 A pt is seen in a specialty practice (that normally does not handle cholesterol) for a separate issue. After that visit, for which there are no acute problems, he asks about his cholesterol. He brought his cholesterol labs to review. He is on a statin and wants to discontinue it because he is "tired of taking so many medicines" and he only had to start taking it because of "new government guidelines". When asked if he had any side effects (eg myopathy) he said he "didn't think so". He took 10 mg lipitor qd. His risk factors included well controlled HTN on a single agent, and age. DM, PAD, AAA, etc were all negative. He was not pre-diabetic. His LDL was in the high 70s (no studies were done on small vs large particle LDL) and his HDL was mid 30s. There was no comparison study to see what his cholesterol was like before initiation of a statin. Ultimately he was deferred to his PCP and told that if the PCP agreed, a trial off the statins and rechecking of blood work would be reasonable. He was also educated about the guidelines and that it was from the AHA and not the government. My question: what would you do in this situation? I do not believe low HDL alone is ever an indication for statins. I have heard DMs without hyperlipidemia still benefit from a statin but have not heard otherwise (although I've heard it advocated for). Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 13, 2014 Share Posted February 13, 2014 Elevated HDL values from statin therapy have not been shown to be as beneficial as a normally (non-med) obtained HDL value. The following are potential causes for a low-HDL that may be correctable w/o medication: elevated triglycerides, obesity, couch potato status, smoker, high carbohydrate diet (>60% of total caloric intake), diabetes (he'd be put on a statin regardless with this dx. since it is a CV equivalent risk), and the following drugs; beta-blockers, anabolic steroids, pro gestational agents; and last but not least, genetics. If he has any or a combination of those above I'd consider a trial off and let him work on the applicable issues. Recheck six months. Remember that you would have to treat patients for 3-5 years with a sample body of greater than one hundred patients for one to benefit (primary prevention only, not following a CV or equivalent event). Link to comment Share on other sites More sharing options...
wjm7 Posted February 13, 2014 Share Posted February 13, 2014 How could you make any decision without knowing his pre-statin therapy levels? Seems like the only decision was to defer to the patient's PCP. Link to comment Share on other sites More sharing options...
primadonna22274 Posted February 13, 2014 Share Posted February 13, 2014 The short answer is to do what you did: defer any advice on this condition to the PCP, especially as your office generally doesn't manage lipids. I'm confident other folks here will give you the long answer but I don't have that much time. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 13, 2014 Share Posted February 13, 2014 I read the OP as being the PCP. WMJ7, a trial off the med will give you your answer. As I previously noted, it probably doesn't matter, regardless. Frankly, assuming that he is like the majority and they are on it preventively, how many of these folks truly meet the recommended guidelines as warranting statin therapy to start with? It's been my experience that very few do, again as a primary prevention therapy. Link to comment Share on other sites More sharing options...
winterallsummer Posted February 13, 2014 Author Share Posted February 13, 2014 I definitely agree that the PCP has to handle this. For all we know he had major issues and is only well controlled now thanks to therapy, and obviously this would be followed by the PCP and changes made accordingly. I guess my real questions are these 1. Is low HDL with acceptable LDL or borderline acceptable LDL ever an indication to treat (maybe in certain pt population)? Granted yes his LDL was certainly at a good number but suppose in another case. 2. Aside from diabetics, is there every an indication to use statins when cholesterol is already acceptable? I have heard "everyone should be on a statin" (see link: http://www.webmd.com/cholesterol-management/news/20100402/should-healthy-people-take-statins and apparently statins can be used in those meeting CAD RFs even with normal cholesterol. Is this being done in practice or should it be? I have known a provider who said anyone over 65 and with HTN, controlled or not, should be on a statin, even if cholesterol is normal. Thanks for all the replies, very helpful. Link to comment Share on other sites More sharing options...
Guest JMPA Posted February 13, 2014 Share Posted February 13, 2014 dc the statin and recommend to the patient to have a repeat blood level in 3 to 6 months. stopping statins is a patients choice. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 13, 2014 Share Posted February 13, 2014 At the levels that you noted while on the 10 mg. of atorvastatin the baseline values couldn't have been too bad to start to obtain such results. As noted previously with regard to HDL, treat reversible causes first without med and also as previously noted, an elevation of HDL from med alone has been shown to not reduce the overall risk that greatly. If you look at the last NCEP guidelines you'll find that primary focus is to be placed upon the LDL (everyone according to their recommendations gets a statin at >190 mg/dL). Below that, you have to factor in other risk factors. Those with documented CVD/DM get a statin regardless. There are basically three cut-offs: >190 mg/dL, >160 mg/dL, and >130 mg/dL. Bottom line, you're hypothetically looking at an LDL of <100 mg/dL, EXCEPT for your DM in whom you want it to be <70 mg/dL, so they say. Now, don't lose sight of the big picture. Remember association and causation. We've for decades chased numbers and based treatment decisions on these numbers. What if the clinical values have no relevance whatsoever and instead the shown benefit from statins is just from being on the statin alone, based upon a rationale that we don't yet understand? Why would I say such a crazy thing? All you have to do is look at the boondoggle that erupted from the study of a statin alone when compared with a combo of a statin and ezetimibe. Combo group had lower LDL values compared to those on a statin only but there was one minor problem. The combo group was dying at a significantly higher rate than the statin alone group, and the manufacturer wasn't letting the study participants know. As I have told my patients, would you rather be alive with a potential higher LDL or dead with great lipid values? This study is why ezetimibe is now listed as a drug of last resort for those with significantly elevated CV risks and who aren't able to obtain goal values with a statin alone, or can't tolerate the statin. Link to comment Share on other sites More sharing options...
dmdpac Posted February 14, 2014 Share Posted February 14, 2014 Count me among those who think you handled this appropriately by referring the patient back to the PCP. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 14, 2014 Share Posted February 14, 2014 Read this again for the third time and realized that you're with the specialty office, not the PCP office. Refer back to prescriber of med since they're the ones treating but at least you've got a little more info now. I will now crawl back under my rock. Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 14, 2014 Moderator Share Posted February 14, 2014 defer to PCP not your issue The PCP thought it wise enough to refer to your clinic for your advice, don't step on his toes (that would be bad form) As for the thought process behind it my thoughts - primary versus secondary prevention? (do you have all the info?) FMH is unknown unlikely this was started with out involving the patient in the discussion of plus and minus only real problem is the low HDL - and only thing that will help that (realistically) is exercise..... you were 100% right to refer back to PCP and anything else would have been wrong. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 14, 2014 Moderator Share Posted February 14, 2014 Referring back to pcp was appropriate. LDLs in the 70's are pretty good, hdl's in the 30s are still low. as a pcp, a trial off would not be a problem but if LDL goes way up and hdl goes down at all that is problematic. a lot of folks can manage to improve their lipid #s just with diet and exercise. some folks can't and require medication. as an endurance athlete with borderline high cholesterol (darn genetics!) I don't want to take a statin. dehydration + statin = greater chance of rhabdo in my book, not something I want during an ultramarathon. I eat pretty well but when the cholesterol creeps up I make a greater effort to improve my diet and exercise more. my goaal is to maintain my high school wt but I typically run 5 or so pounds over. my most recent food item dropped in the name of bettering my cholesterol was half/half in coffee at restaurants and other places( I already use the fat free stuff at home). now I ask for milk or just drink it black. I do the niacin/fish oil/garlic/flax seed oil too and I think it helps. Link to comment Share on other sites More sharing options...
cbrsmurf Posted February 14, 2014 Share Posted February 14, 2014 Referring PCP, is the correct choice. On the primary care side of things, discontinuing statins may be reasonable if his only risk factor is well-controlled HTN. We should all remember, however, that most medications, including statins, you get the greatest benefit change from the initial (lowest dose). If you take him off, his LDL could shoot back up. Another thing to consider, as I think it was mentioned, the newest guidelines reflect the growing body of literature that cholesterol levels are not as strongly associated with cardiovascular risk as we once thought. Third thing to consider, is that statins are one of the most effective and safest medications to reduce cardiovascular risk. Rhabdo and myalgia are rare, and other drugs within the class (i.e. pravachol) have even lower risk. If a patient is trying to cut down on his meds, you have to perform a proper risk assessment, but I usually try to keep them on it. Link to comment Share on other sites More sharing options...
Guest JMPA Posted February 15, 2014 Share Posted February 15, 2014 i have no issues with educating patients about medication use and benefits even if it overrides their PCP recommendations. there are a lot of prescribe for profit mds out their. a trial of stopping the statin is the best course whether or not the pcp agrees. do what is best for the patient Link to comment Share on other sites More sharing options...
wjm7 Posted February 15, 2014 Share Posted February 15, 2014 Third thing to consider, is that statins are one of the most effective and safest medications to reduce cardiovascular risk. Rhabdo and myalgia are rare, and other drugs within the class (i.e. pravachol) have even lower risk. Statin induced myalgia actually isn't that rare, unfortunately. Still great drugs, though. Wonder drugs, really, for people that can take them without any side effects. But screening for muscle pain is pretty important. Link to comment Share on other sites More sharing options...
primadonna22274 Posted February 15, 2014 Share Posted February 15, 2014 The point is the specialist doesn't have all the information necessary to advise the patient optimally. If I'm the PCP referring my patient for specialty care and the specialist ventures beyond his/her expertise and confuses my patient, I'm pissed and the patient is potentially harmed. And you can bet that specialist isn't getting any more referrals from me. Link to comment Share on other sites More sharing options...
wjm7 Posted February 15, 2014 Share Posted February 15, 2014 The point is the specialist doesn't have all the information necessary to advise the patient optimally. If I'm the PCP referring my patient for specialty care and the specialist ventures beyond his/her expertise and confuses my patient, I'm pissed and the patient is potentially harmed. And you can bet that specialist isn't getting any more referrals from me. Yeah, that was my thinking. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 15, 2014 Share Posted February 15, 2014 Let's forget about the PCP/specialty component of this discussion for a moment and let's assume that this is a 50 something male, non-smoker, no DM/HTN/PVD in his personal history and a pretty sedentary lifestyle. His FH is positive for a "mild heart attack" in dad at age 65 but no further issues since (let's say dad is now 70). He comes to see you for the first time with the OP presentation and associated lab values. You all seem to agree that a trial off the statin is acceptable and we'll assume for the sake of discussion that he is going to be reliable and RTO in 6 months for recheck. At what values do you consider medication? I know what I would do/have done but I'm now curious to see how others would address this. He is compliant and "willing to try whatever you tell me to do". Let's also assume that the prescriber never mentioned side effects risk or when most likely to occur. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 15, 2014 Moderator Share Posted February 15, 2014 He is compliant and "willing to try whatever you tell me to do". chances are you can keep him off the statin with lifestyle modification then, don't you think? ( lose 25 lbs, walk 30 min/day, diet modification, etc). Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 15, 2014 Share Posted February 15, 2014 Okie dokie, let's see what others have to say. This is one of those rare folks who really wants to assist with making an informed decision and wants to be healthy. After all, how many want to have a CV event? Link to comment Share on other sites More sharing options...
wjm7 Posted February 15, 2014 Share Posted February 15, 2014 I think I would want to know more about the father's history. If he didn't have many risk factors, I would be more likely to go with statins for the patient even with stereotypically good cholesterol numbers. Statins are extremely cardioprotective, and that's only partly because of reductions in cholesterol. Plaque stabilization, immunomodulation, improved endothelial function... Lots of good reasons to keep a person with a likely genetic (and lifestyle) predisposition to cardiovascular disease on a statin. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 15, 2014 Moderator Share Posted February 15, 2014 this bothers me a bit.... http://www.webmd.com/cholesterol-management/news/20130523/could-statins-raise-diabetes-risk Link to comment Share on other sites More sharing options...
wjm7 Posted February 15, 2014 Share Posted February 15, 2014 Interesting. Regardless, pravastatin seems to be good, even if you are worried about the type II DM risk. And as they said, "the overall odds of developing diabetes were low in patients prescribed statins." I previously did graduate work with statins and mitochondrial function (in a lab that did a lot of work regarding mitochondria/insulin resistance/type II diabetes), so I do find the association interesting. Hopefully I'll have time to delve into the literature again at some point. Maybe in between didactic and clinical year... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 15, 2014 Share Posted February 15, 2014 Ah, so WJM7 you touch on an interesting topic, endothelial stabilization and reduction of inflammation with statins yet no mention is made with regard to the almighty numbers (you're not playing fair here :) ). Do others wish to provide information as to how they would base their decision clinically with regard to how numerical values that are obtained in six months impact their decision and pt. discussion, since I think we're all in agreement that as with just about any serious disease process that potentially increases CV risk we're going to recommend applicable TLCs? BTW, how much of an impact can we realistically expect with regard to lipid values from TLCs alone that are adhered to (assume no statins are involved at this point)? Link to comment Share on other sites More sharing options...
cbrsmurf Posted February 15, 2014 Share Posted February 15, 2014 this bothers me a bit.... http://www.webmd.com/cholesterol-management/news/20130523/could-statins-raise-diabetes-risk Yes, statins raise sugars a tiny bit. So the patient who was at a fasting glucose of 120 is now 125/135/or 145 and technically diabetic. Does his dx of "diabetes" post-statin put him at much higher risk than having the benefits from being on a statin? We should remember that the criteria for diabetes is just an arbitrary lab value. Link to comment Share on other sites More sharing options...
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