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What is the deal with cholesterol medications?

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A discussion of what cholesterol medications are out there and what the pros and cons of some medications are. We look at statins versus other options and why doctors tend to go them first.

So we’re going to talk about something today that is probably one of the most frequent questions that comes up in primary care that is do i need to take a medication for high cholesterol um there’s no clear-cut answer for everyone as you might imagine and it is something that is contentious with some patients and i think they have legitimate concerns it is

A very common problem at least high cholesterol in western society because of our diet and lifestyle so let’s just go through and talk about what medications are out there to manage cholesterol and what what the reasons are why would you want to do it when would you want to do it and try to help get a perspective from a patient’s perspective on how why and

When you might want to consider taking medication for cholesterol so why would it matter why would you even want to consider taking medication for cholesterol the reason is lower cholesterol specifically lower hd sorry ldl cholesterol and total cholesterol and triglycerides decreases your risk of having a heart attack or stroke hdl cholesterol or good cholesterol

Is a little bit of a different story and you actually want it to be higher it’s often termed your quote good cholesterol how can you get your cholesterol down um diet to some degree for sure weight loss exercise and medication we have some videos that are kind of focused on the diet and exercise side of this question and i would refer you to those i think yeah

That that’s the first line that has um benefits across the board really no downside other than being difficult and having to give up a few uh treats that we all enjoy but but it’s really the best way to control your cholesterol so if that’s not an option or you’ve reached the point where you’ve developed cardiovascular disease you’ve had a heart attack you’ve

Had a stroke then then you really need to be on one of these medicines studies that that have looked at this basically say you want your ldl cholesterol to be under about 70 if you’re in this category that’s got non-vascular disease so set those aside should people who don’t have those be on cholesterol medicine the answer is yes but it is a nuanced yes if you

Have no non-history of cardiovascular disease you know stroke heart attack then basically you’ve got to make some estimate of your risk of developing one of these diseases over the next period of time usually 10 years is used and use that to inform your decision and help you and your provider decide is it worth taking this medicine every day for 10 years to try

To decrease my risk of a bad event so in this setting you’re not going to be as aggressive frequently a number of around 100 is used for ldl cholesterol you’re going to use some tool either your clinician’s clinical gestalt or some calculator that’s been derived through clinical studies a common example would be the ascvd risk calculator that’s useful in ages

Of about 40 to 79 and gives you basically a percentage chance of a given person having a heart attack or a stroke based on some parameters blood pressure cholesterol levels weight race age gender whether or not they smoke there may be some others in there that i’m not pulling up off the top of my head but basically you pull this up online run it through plug the

Numbers in calculate it and you have your your estimated risk um so if you’re above about 10 you probably should be on medicine if you’re between 5 and 10 it’s a bit harder to know what the right answer is uh some people would say 7.5 and above so with that said you you’ve got your people with known disease non-vascular disease and you have your people with

Uh kind of an increased overall risk of having developing vast vascular disease over the next 10 years you have a couple of special groups you have people with high cholesterol high triglycerides that is an independent risk factor for heart disease dietary interventions lifestyle changes frequently will control triglycerides if if you’re able to be focused and

Really stay with it over time for triglycerides you’re going to want to start with a statin in most cases some cases you’re going to follow up with a fish oil derivative like a omega-3 fatty acid acasapent ethyl is probably the best studied with the best evidence um we’ll come back to that in a little more detail there is a subgroup of people who will have

Significantly elevated triglycerides and will need to be on a one of the medicines in the fibrate family to help prevent complications like pancreatitis we’re not really going to go into that but know that that it exists and might be a reason why those medicines are used to manage their elevated triglycerides and some clinicians use the fibrates in the setting

Of elevated triglycerides believing that it probably does have some benefit in decreasing your cardiovascular risk but that’s not as well proven um you you basically have two other groups that you want to think about when you’re trying to weigh out should they be on a statin people with diabetes pretty much their risk is two to three times the population’s

Risk of having a heart attack or stroke or cardiovascular disease more more globally so moderate or high intensity statin therapy is recommended for most of the older adults with diabetes especially if they have other risk factors for cardiovascular disease older adults kind of a nuanced question i think it basically boils down to expected life expectancy and

Relative risk of heart attack or stroke so that’s a discussion to have with your provider in an individualized setting but there may be situations where it doesn’t make sense to continue taking a medication that might have side effects unless there’s some good reason to think that it’s doing something for extending life and preventing morbidity or illness and

Difficulty so what medications are are there to consider um the statin family gets all the press and all the attention and and really all the debate from patients for the most part there are a lot of medicines in this family uh common ones would be atorvastatin lovastatin pravastatin rasuvastatin you’ll see the trend they end in the with statin they’re the

Best study they’re the most effective at preventing cardiovascular disease heart attack stroke and death if you try to figure out how much it’s it’s a difficult thing to nail down looking at the studies but probably up to 25 reduction in risk in some situations maybe less maybe more that gives you a number to to work with in your mind that’s certainly not across

The board but um statins work by decreasing the body’s production of cholesterol increasing removal of the cholesterol by the liver probably also reduces inflammation some which may prevent heart attacks and strokes i typically decreases your ldl cholesterol level by about 25 to 55 percent which is a very significant reduction has some annoying side effects in

Some people if you really look at it in the setting of a randomized controlled trial where patients don’t know if they’re taking the medication or not the the rates are not that bad but the the side effects that it can cause are so common it’s hard to tease out in real life if you’re having some type of side effect from the medication sometimes the side effects

That that we’re referring to are muscle aches um feeling achy all over people sometimes will attribute it to their joints weakness fatigue rarely some more severe side effects like feeling muscle having muscle breakdown that leads to pretty profound weakness very rarely can cause rhabdomyolysis where the the breakdown of muscle cells releases chemicals into the

Blood that ultimately kind of stop up the kidneys can get liver disease and dysfunction from from statins although that’s clinically really rare you’ll see some elevation and liver enzymes fairly uh routinely but that is unusual for that to become a real clinical problem so there are side effects the problem is is looking at the risk benefit ratio and deciding

Is it really more likely to help you or more likely to hurt you and that’s something only you and your physician or your provider can sort out on an individual basis so taking them in the statins correctly is something that’s important to to consider um some are better taken with food some are better taken at bedtime uh clarify it with your pharmacist or

Your provider i may even say it on your bottle when you get it from the pharmacy so statins aside they’re they’re the ones with the most evidence let’s look at your other options a zeta mime brand named zedia in the us decreases body’s ability to actively absorb cholesterol from food as well to as well as to use cholesterol produced in the body it decreases

Your ldl cholesterol about 20 percent is generally pretty well tolerated when used in combination with a statin has some evidence that it may change your cardiovascular risk profile but use by itself doesn’t really have great evidence though it stands to reason that it probably has some overall it is a reasonable second line choice bile acid sequestrants we

Don’t use these as much they’re old medicines i i have a hard time saying the names of some of them cholesterol brand name welcome cholestopol uh brand name cholesteed um cholesteramine brand name previla sorry prevolite and questran um these medications basically bind some bile acids in the intestine decrease absorption of cholesterol they decrease the ldl

Cholesterol by about 10 percent their tools that are out there they’re relatively well tolerated but not something that we reach for very often pcsk9 inhibitors is a newer drug class they have also gone the difficult to pronounce name route and are alira kumab a brand name paluent evolucumab brand name repatha um these are actually given as injections

Every two to four weeks they are very effective at reducing ldl cholesterol levels by up to 55 60 percent they have relatively few side effects some localized injection site reactions are are seen but but not bad not frequent um they’ve been shown to reduce your risk of heart attack and stroke and potentially death over a period of time they’re expensive so

Because of that they get limited to people who cannot tolerate statins or are uncontrolled on a maximum dose of a statin uh and a zeta mibe and the use is really restricted to people who have non-cardiovascular disease um or potentially someone with a genetic disorder like a familial hypercholesterolemia um omega-3 fatty acids is another category that’s got

Some utility oily fish such as tuna mackerel sardines salmon herring there have been studies that show that if you have one to two servings per week of these oily fish in your diet that you can decrease your risk of heart attack and or stroke significantly you can also decrease your triglycerides significantly over-the-counter supplements don’t really have good

Evidence that they can can achieve these reductions and and risk over the long term um icosapent ethyl brand name vasepa in the united states at a dose of four grams per day has been shown to have some reduction in cardiovascular risk over the long term this is expensive and it is something that you should consider better is probably to make the dietary

Changes and the lifestyle changes and then if your physician or provider recommends that you add it and it’s feasible from a financial perspective then it may be something that that has some demonstrable benefit niacins and older medicine has some annoying side effects like flushing and numbness it can make gout worse it can cause liver damage can reduce your

Cholesterol some it’s not really used that much anymore in most cases there are some older patients who’ve been on it for a long time and tolerate it fine and and it may well be completely fine to keep them on it if it’s been effective um so that that gives you a framework of thinking about what cholesterol medicines are out there um when they might or might

Not be indicated for a given patient to take and a way to discuss with your provider the the recommendations that they’re making and to understand them i hope you’ll take some time to go through our videos on diet and exercise i think that’s really the nuts and bolts of this for definitely the primary prevention side of things so i hope you will look at those and

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Transcribed from video
What is the deal with cholesterol medications? By Sheppard MD