Jump to content

Pts wanting to d/c statins due to "ok cholesterol", and low HDL ???


Recommended Posts

  • Moderator

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.

probably makes his insurance premiums go up....

Link to comment
Share on other sites

  • Replies 53
  • Created
  • Last Reply

probably makes his insurance premiums go up....

now that he has less expendable income he saves money by buying junk food.  then he gets fat, anxious and depressed, tries various street drugs because it gives him a few minutes of euphoria from his now unfulfiling life.  He's now addicted to xanax and heroin and has cirrhosis from getting hepc from a used syringe.  oh god, what've we done???

Link to comment
Share on other sites

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.

 

I'm not sure this applies to primary prevention though.

Link to comment
Share on other sites

TLC's (therapeutic lifestyle changes) reportedly lower the LDL value up to fifteen percent (I've seen some even better results but at least it's a round number) per the NCEP/ATP III guidelines.  wjm7 brings the point home with regard to what the statin is actually doing at the cellular/plaque level.  If the presumed benefit from the statin, as we understand it today, is plaque stabilization and endothelial inflammation reduction, what role do the actual lipid values play?  Are they an association?  Are they causation in nature?  Are we chasing our tails by chasing the numbers?  This doesn't even take into consideration the type of plaque the patient may have, which at present time we can't clinically differentiate unless profoundly calcified (felt to be more stable).

 

This is why I had previously brought up the Zetia (ezetimibe) study.  We saw much lower LDL's in the Zetia/Zocor group but the pt.'s were dying in comparison to the Zocor alone group.  The point that I'm trying to make, and the reason why I asked others what they would do if they were seeing this pt. as the primary provider and such a question had been raised, is that we honestly don't know the answers (or at least I don't).  We know that the "experts" say that for anyone with an LDL >190 mg/dL to put them on a statin.  For diabetics, or those with a prior hx. of CV event(s), we're told to not only put them on one but to shoot for LDL values <100 mg/dL and preferably <70 mg/dL.

 

Discogenic drives home the point that in reality we're talking about two separate population groups.  The majority, "virgin" CV folks, are the ones that drive the statin marketplace yet by evidence seem to benefit the least.  The flip side, or minority by far, are those that are in-house about to leave out the front door of the hospital after their event and you're throwing a statin in their Cheerios as they finish breakfast because they seem to benefit in a much more substantial manner.  Each group has the same lipid numbers but they're reacting differently!  

 

As was pointed out in previous threads, if you look at the study out of the Univ. of British Columbia pharmacy school about a decade back, the NNT was greater than one hundred at a retail cost of approximately $3/day for five years.  That's a lot of cash as a CV virgin to be laying out for a one in a hundred chance of "winning the CV lottery".  Subsequent studies have even demonstrated that the NNT is greater.

 

Getting back to the example pt., I would expect, all things being equal, to find that off meds the LDL will probably get back to about 130 mg/dL based upon the current dose of atorvastatin.  At such a value, ACEP/ATP III says that medication is optional and that pro's/con's should be discussed with the pt..  All this being said, since this NNT data has been made known to myself, I've yet to have a "virgin" patient elect to take the medication after factoring in the variables/cost with an LDL value in this range (<145 mg/dL for example).  Once they start hitting the 160 mg/dL level some have elected to take the medication if for example there is a hx. of a first degree relative with a CV event if a male <55 y/o, or a female <65 y/o (this is why I commented that dad was 65 y/o at the time of his event).

 

When it's all said and done, I think we're going to find that the decision will ultimately be based on personal risk factors as discogenic has pointed out, and not so much on numerical values (which is where the recently released recommendations started to head).

Link to comment
Share on other sites

If anyone is interested, here is a 1 hour podcast from a few weeks ago that delves into the literature regarding statins and primary prevention.  I'll warn you, it's very wonky and very stats-heavy.  He dissects a number of the important studies on the topic in greater detail than I ever would on my own. 

http://www.smartem.org/podcasts/smart-statins

Link to comment
Share on other sites

  • Moderator

I think I'd shoot for nasal steroid sprays first. I'm not in the group that necessarily considers them "safe", especially for first six months of therapy since that is the time interval when side effects are most likely to arise (based on memory).

I agree. statins are not benign txs...

Link to comment
Share on other sites

It's hard to believe that 10 mg of atorvastatin took a really bad LDL and made it 70 something. And that's a low goal for the case, unless he has a strong family history.

 

In cardio, we'll deal with statins if the PCP doesn't test (which happens sometimes), the patient asks us to, or if the patient doesn't have a PCP. We usually defer to the PCP, but I put in my consult report what the goal should be, considering the results of his cath and other risk factors. We have, for example, some people with severe triple vessel disease, multiple stents, and multiple bypasses that are beginning to occlude. Now there is a 70-something.

Link to comment
Share on other sites

I agree that statins aren't shown to be effective tx's for primary prevention in most cases.  Furthermore, evidence is weaker for women, as well.

 

 

As for safety profile, it's one of the safer drugs in the pharmaceutical cornucopia.  With patient's who said they couldn't 'tolerate' statins of my pts from other providers, I've titrated up from half of minimum doses and it works roughly 75% of the time.

Link to comment
Share on other sites

TLC's (therapeutic lifestyle changes) reportedly lower the LDL value up to fifteen percent (I've seen some even better results but at least it's a round number) per the NCEP/ATP III guidelines.  wjm7 brings the point home with regard to what the statin is actually doing at the cellular/plaque level.  If the presumed benefit from the statin, as we understand it today, is plaque stabilization and endothelial inflammation reduction, what role do the actual lipid values play?  Are they an association?  Are they causation in nature?  Are we chasing our tails by chasing the numbers?  This doesn't even take into consideration the type of plaque the patient may have, which at present time we can't clinically differentiate unless profoundly calcified (felt to be more stable).

 

This is why I had previously brought up the Zetia (ezetimibe) study.  We saw much lower LDL's in the Zetia/Zocor group but the pt.'s were dying in comparison to the Zocor alone group.  The point that I'm trying to make, and the reason why I asked others what they would do if they were seeing this pt. as the primary provider and such a question had been raised, is that we honestly don't know the answers (or at least I don't).  We know that the "experts" say that for anyone with an LDL >190 mg/dL to put them on a statin.  For diabetics, or those with a prior hx. of CV event(s), we're told to not only put them on one but to shoot for LDL values <100 mg/dL and preferably <70 mg/dL.

 

Discogenic drives home the point that in reality we're talking about two separate population groups.  The majority, "virgin" CV folks, are the ones that drive the statin marketplace yet by evidence seem to benefit the least.  The flip side, or minority by far, are those that are in-house about to leave out the front door of the hospital after their event and you're throwing a statin in their Cheerios as they finish breakfast because they seem to benefit in a much more substantial manner.  Each group has the same lipid numbers but they're reacting differently!  

 

As was pointed out in previous threads, if you look at the study out of the Univ. of British Columbia pharmacy school about a decade back, the NNT was greater than one hundred at a retail cost of approximately $3/day for five years.  That's a lot of cash as a CV virgin to be laying out for a one in a hundred chance of "winning the CV lottery".  Subsequent studies have even demonstrated that the NNT is greater.

 

Getting back to the example pt., I would expect, all things being equal, to find that off meds the LDL will probably get back to about 130 mg/dL based upon the current dose of atorvastatin.  At such a value, ACEP/ATP III says that medication is optional and that pro's/con's should be discussed with the pt..  All this being said, since this NNT data has been made known to myself, I've yet to have a "virgin" patient elect to take the medication after factoring in the variables/cost with an LDL value in this range (<145 mg/dL for example).  Once they start hitting the 160 mg/dL level some have elected to take the medication if for example there is a hx. of a first degree relative with a CV event if a male <55 y/o, or a female <65 y/o (this is why I commented that dad was 65 y/o at the time of his event).

 

When it's all said and done, I think we're going to find that the decision will ultimately be based on personal risk factors as discogenic has pointed out, and not so much on numerical values (which is where the recently released recommendations started to head).

 

also, ezetimibe is a terrible drug.  it should probably never be used.

Link to comment
Share on other sites

That's why it now is categorized as a "drug of last resort", though quite a few folks remaIn on it for reasons unknown in my experience.

 

Everything from a pharmaceutical perspective is different...so says 60 Minutes. Sad thing is no one ever thought that there would be a difference between males/females, except for those "nasty hormones" I believe is how they quoted it.

Link to comment
Share on other sites

It's hard to believe that 10 mg of atorvastatin took a really bad LDL and made it 70 something. And that's a low goal for the case, unless he has a strong family history.

 

As an example, when I was first put on this specific dose by an internist back in the early 90's my LDL was in the 130's mg/dL range (it's never been above this).  I for the most part have continued on it, with limited periods off just to see what my values would do, only because I tolerate it fine, there was the original suspicion that it could also lower the risk for colon ca, and it did bring my LDL down to this range and my HDL from mid/upper 30's to just over the top of the bar of 40 mg/dL.  Now, as noted above, the benefit of the HDL increase by pharmacologic means is questionable at best.  HbA1c values have been normal throughout.  If I were talking to myself as the patient I wouldn't push for them to take it obviously based on what I've previously said.  Why stay on it?  Potential for plaque stabilization which develops in all of us to some degree for those who strive to keep In/Out, BK, and McD's in business, and I know what side effects to watch for.  Cost also isn't a factor with the generic availability.  There is no way I'd pay OOP for name brand.

Link to comment
Share on other sites

I'm watching this thread with interest, since I am due for my annual checkup this week and need to find a way to tell my PCP that I haven't been very compliant with my 10mg of simvastatin. He had me on 30 just for the hell of it, apparently, and last year he agreed to cut it to 10 and see what the numbers did. I did get pretty noticeable myalgias on 30mg/day, and when you're supposed to be exercising, in my experience there is no better excuse not to.

 

I do take my lisinopril daily, and risk-factor wise I'm not the worst and not the best, but I really hope my blood work doesn't screw me over. I'd like to quit the statin entirely, rather than half-assedly take it when I remember.

Link to comment
Share on other sites

Archived

This topic is now archived and is closed to further replies.


×
×
  • Create New...

Important Information

Welcome to the Physician Assistant Forum! This website uses cookies to ensure you get the best experience on our website. Learn More