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The State of Statins (Cholesterol Lowering Drugs)

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We’ve known for quite a while that lowering your cholesterol can reduce your risk of heart disease, heart attack, and stroke.   Low fat diets, weight loss, and exercise can help people to control their cholesterol levels – but for those who do not succeed with these methods, a class of medications have been developed (known as “statins”) to reduce cholesterol.  These drugs have been so successful at reducing cholesterol that some doctors have joked about putting statins in the water supply.  In fact, 36 million Americans take a statin every day, generating annual sales of
$15.5 billion for the manufacturers, and making two statins – Lipitor and
Zocor – the top two best-selling drugs in the USA.

Four new studies were published in the past week about these drugs.  I thought I’d summarize the findings for you to keep you up to speed with the very latest statin information.

Statins May Reduce Mortality After Having A Stroke

Spanish researchers followed the progress of 89 stroke patients who were already taking statins.  For the first three days after the stroke, 46 patients received no statins, and 43 got their normal dose.  After three months, 27 people – 60 % of the “no statins”
group – had either died or were disabled to the point that they needed
help to live a normal life, compared with 16 people from the group
allowed to keep taking statins.
This small study suggests that stroke patients should not stop taking their statins.  More research is needed to clarify the role of statins in stroke.

Statins May Reduce The Brain Plaques Associated With Alzheimer’s Disease

Researchers at the University of Washington examined the brain tissue of 110 people who had donated their brains to research upon their death.  They found there were
significantly fewer plaques and tangles (the hallmarks of Alzheimer’s disease) in the brains of people who had taken statins compared with those who had not.  This is good news, but will require further research to determine whether or not statins could be used (or should be used) specifically for the treatment or prevention of Alzheimer’s Disease.

Statins Don’t Seem To Reduce The Risk of Colon Cancer

A group of Greek researchers conducted a review of the scientific literature to see if there may be a reduction in colon cancer rates among people who take statins.  They found no evidence that statins reduce the risk of colon cancer.

Statin Side Effects Appear To Be Ignored By Some Physicians

The journal Drug Safety surveyed 650 patients about their experience with statins.  Eighty-seven percent of patients reportedly spoke to their physician
about the possible connection between statin use and a symptom.
Physicians were  more
likely to deny than affirm the possibility of a connection. Rejection
of a possible connection was reported to occur even for symptoms with
strong literature support for a drug connection.  This report is concerning since it seems to suggest that physicians don’t take patient complaints as seriously as they should.

I asked Dr. Frank Smart what he thought about the side effects of statins and whether or not physicians should be more aware of them.

“The statin side effects exist
but in my opinion are overplayed. In my practice about 5% of people on statins
have some muscle issues. Most improve with dose reduction or change to a more
hydrophyllic compound.

Physicians should be better educated about side effects and the one who
should do the educating is pharma, and websites like Revolution Health.  Most docs are as
familiar with statin side effects as they are with other drug classes, so good
but not great. We would all love to raise the bar but it is tough as you
know.”

As many as 30% of patients reportedly experience a side effect from statins (including: headache, nausea,
vomiting, constipation, diarrhea, rash, weakness, and muscle pain) though severe muscle damage is very rare (for example, one article reported 24 cases in 252,460 patients.)  Overall, statins have many health benefits and are well tolerated by the majority of patients.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The High Tech Approach To College Camaraderie

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The Washington Post featured an article about how social networking tools like Facebook are influencing student socialization at college.  Some say that the frenetic texting, online communications, and iPhone chatter are causing students to lose the ability to socialize normally in-person.  Others say that technology levels the social “playing field” for introverts.  I interviewed Revolution Health’s psychologist, Dr. Mark Smaller, to get his thoughts on the matter.  Feel free to add your perspective in the comments section of this blog.

Dr. Val: The article
suggests that technology can become a social crutch, keeping people from making
new friends.  Do you think that the
Internet can isolate students from one another?

Dr. Smaller: I think the long term impact of the Internet in
social interactions is unclear.  For now
such technology does allow students to remain in touch with one another
instantly, but that’s not too different from what the telephone did for
previous generations.  If anything, I’d
say that technology can interfere with isolation, especially for the new
college student away from home for the first time.  If there is a propensity for isolation, any
activity in excess – reading, school work, drinking, etc. will become the means
to continue that isolation.

Dr. Val: Do you think
that social networking and Internet based methods of communication are
particularly healthy for introverts?

Dr. Smaller: Being able to communicate sincerely or
genuinely but indirectly and not in person may help the otherwise shy person.  Some of our most brilliant artists and
writers have used their craft as a means to communicate to others in ways they
could not in social situations.

Dr. Val: Overall do
you think that socializing via the Internet is a good thing or a bad thing for
college students?

Dr. Smaller: One things is certain on and off the Internet:
relationships for children, adolescents, and adults can become quite intense
with this way of communicating because of fantasy and anonymity.  Previous generations used the art of letter
writing to express intense feelings, followed by the telephone, and now online
communication.  What they all have in
common is the essential human need to connect – including the satisfaction of
doing so and the frustration when it chronically does not occur.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Preventive Care Can Keep You Out Of The Hospital

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In a recent study conducted by the Agency for Healthcare Research and Quality (AHRQ), it was argued that better primary care could prevent 4 million hospitalizations per year.  This staggering potential savings – on the order of tens of billions of dollars – seems like a good place to start in reducing some of the burden on the healthcare system (and reducing unnecessary pain and suffering).  I interviewed Dr. Joe Scherger, Clinical Professor of Family & Preventive Medicine at the University of California, San Diego School of Medicine (UCSD) and member of the Institute of Medicine, to get his take on the importance of prevention in reducing health costs.

Dr. Val:  What do the AHRQ
statistics tell us about the role of primary care in reducing healthcare
costs?

Volumes!

Primary care works with the
patient early in the course of illness, maybe even before it has developed, such
as with prehypertension and prediabetes.  Primary care focused on prevention
with patients keeps people healthier and out of the
hospital.

Dr. Val: What can individual
Americans do to reduce their likelihood of having to be admitted to the
hospital?

Prevention begins with the individual,
not the physician.  60% of disease is related to lifestyle.  Bad habits such as
smoking, overeating, not being physically fit, and stress underlie most common
chronic diseases.  If Americans choose to be healthy and work at it, we would
save tremendously in medical expenses.

Dr. Val: Are there other studies
to suggest that having a medical home (with a PCP) can improve
health?

The medical home concept is new and lacks
studies, but the work of Barbara Starfield and others have confirmed the
importance of primary care and having a continuity relationship with a primary
care physician.  The more primary is available, the healthier the population.
The opposite is true with specialty care.

Dr. Val: Why did the
“gatekeeper” movement (promoted by HMOs) fail, and what is the current role of
the family physician in the healthcare system?

The
“gatekeeper” role failed because it restricted patient choice.  Patients need to
be in control of the health care, which is what patient-centered care is all
about.  HMOs put the health insurance plan in charge, something which was hated
by patients and their physicians.

Dr. Val: In your work with the
IOM (specifically in Closing the Quality Chasm) did the role of primary care and
preventive medicine come up?  If so, what did the IOM think that PCPs would
contribute to quality improvement in healthcare?  Did they discuss (perhaps
tangentially) the cost issue (how to reduce costs by increasing preventive
measures?)

Just before the IOM Quality Reports
came out, the IOM did a major report on the importance of primary care.  The
importance of primary care and prevention are central to improved quality.  In
the “Chasm Report”, the focus was more on the patients taking greater charge of
their health care, and the realization that primary care is a team effort, and
not just a role for physicians.  The reduction in costs comes from making health
care more accessible (not dependent on visits) through health information
technology and the internet.  Preventing disease, and treating it early when it
comes, are the keys to quality and cost reduction.  Revolution Health is a
vehicle for this, consistent with the vision of the “Chasm Report.”

Dr. Val: How can patients be sure that they’re getting the best primary care?

First take charge of your
own primary care.  The traditional patient-physician relationship was, “Yes
doctor”, “Whatever you say doctor”.  Your care would be limited by the knowledge
and recall (on the spot) of your doctor.
Much better is a “shared care” relationship with your primary care
physician and team.  After all, the care is about you.  Be informed.  Make your
own decisions realizing that the physician and care team are advisors, coaches
in your care. You may agree with them, or disagree and do it your way.  By
having your own personal health record and being connected to resources like
Revolution Health, you are empowered to get the care you want and need.
Finally, choose your primary care wisely.  Not just anybody will do.  Your
primary care physician is as important a choice as your close friends.  You need
to like and trust this person.  Have a great primary care physician who knows
you and cares about you and your health care is in real good shape.  But, no
matter how good she or he is, you still must take responsibility for your care.


This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Weight Loss: Another Scary Option

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I came across an interesting weight loss invention this weekend that proposes to allow people to have their cake and eat it too.  Scientists have constructed a kind of plastic intestinal condom to block digestion of food.  Since gastric bypass surgery essentially reduces food absorption while decreasing stomach size, this removable plastic lining could act as a sort of non-invasive alternative to such a permanent procedure.  Sounds intriguing?

Well, before we get our hopes up, it’s always best to check with the gastroenterologists.  I dropped Dr. Brian Fennerty a note to ask him what he thought of this proposed weight loss solution.  His response was enlightening – “The Endobarrier Gastrointestinal Liner is potentially very dangerous as it may block the pancreatic duct and cause pancreatitis, dislodge resulting in bowel obstruction, or ulcerate. There are no comparative trials and as such I would consider it investigational at best.”

Why is blocking the pancreatic duct scary?  The pancreas is a little organ that should get a lot more respect, in my opinion.   It produces enzymes that are secreted into the intestine to break down food – I like to think of the pancreas as a bag that contains acid as strong as Alien blood (those of you who’ve seen the movie will get that reference).  Basically, the pancreas can liquify a steak – so plugging up the exit route for those enzymes is a really bad idea.  You can imagine why pancreatitis is so painful.

And then there’s the risk of the liner getting loose and wadding up in a plastic ball and blocking your bowels, or the risk of the plastic irritating the intestinal lining and causing an ulcer which could bore a hole straight through your gut.

Well, I don’t mean to resort to scare tactics here… but honestly, this procedure has serious risks that one doesn’t really get from the media’s article on the subject, “New Procedure Could Help Millions.”  So be careful out there folks – always check with your doctor before you try something new to lose weight.  I’m afraid that diet and exercise are really the safest options out there.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Beta Blockers Might Not Be Good First Line Therapy For High Blood Pressure

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A new study in the Journal of the American College of Cardiology (August 14th issue by Bangalore et al.) questions the evidence behind using beta blockers as fist line therapy for high blood pressure.  It seems that these medications may actually increase the risk of stroke, especially in the elderly population.  The following drugs are all beta blockers:

  • Atenolol (Tenormin)
  • Metoprolol (Lopressor, Toprol-XL)
  • Propranolol (Inderal, Inderal LA)
  • Carvedilol (Coreg)

As many as 60 million Americans have high blood pressure, and many of them are currently taking beta blockers.  I asked Dr. Frank Smart, chairman of the department of cardiovascular medicine at Atlantic Health in New Jersey, what he thought of this new study.

1.  What is a beta
blocker?

Beta blockers are a class of drugs that exert their effects on the heart by blocking the effects of adrenaline.  This results in a slower heart rate and reduced blood pressure.  They can also protect you from rhythm disturbances.

2.  What did this study show?

Beta blockers have a lot of important uses, but this analysis shows that they’re not as effective as (and may have more side effects than) other therapies for the treatment of high blood pressure.  In the past, we physicians thought, “Well, shucks, if beta blockers are good to use after a heart attack, and people with high blood pressure are at risk for having heart attacks, then maybe we should use a beta blocker to treat the blood pressure.”  This study contradicts this thinking, suggesting that the beta blockers are inferior to other therapies.  In other words, we should use beta blockers for the conditions that they’re known to be good for, but we should not infer that they are best for blood pressure management when there are better drugs available.

3.  Will the findings of this study
change your practice?

Yes they will.  I’m one of those people who have used beta blockers on occasion to treat high blood pressure in patients whom I thought were also at high risk for heart attack.  I probably won’t use beta blockers as first line treatment in those individuals anymore.  I’m going to stick with diuretics or renin-angiotensin system blockers.

4.  What do these findings mean for
people with high blood pressure?

It means that they should follow the guidelines indicated for the treatment of high blood pressure.  It involves a step-wise approach, with diuretics being that first step.  Any therapy is better than no therapy, and controlling high blood pressure is critically important, but beta blockers (as a monotherapy) are probably not as good as other treatments.

5.  When would you recommend the use of
beta blockers?

Beta blockers are a very important class of drugs for many cardiovascular diseases.  Anyone who’s had a  heart attack needs to be on a beta blocker, anyone who has congestive heart failure (CHF) and can tolerate a beta blocker should be on one, and hypertrophic cardiomyopathy requires treatment with beta blockers.  Beta blockers can control certain heart rhythm disturbances, and can reduce the risk of adverse cardiovascular events during surgery.

6.  What’s the take home message from
this study?

When treating high blood pressure, we should use drugs that have been shown to have the greatest reduction in mortality.  Don’t assume that the valuable effects of beta blockers (for people who’ve had heart attacks) automatically translate into benefits for people with high blood pressure.

Want to hear the full conversation?   Listen to the podcast with Dr. Smart

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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