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The State of Statins (Cholesterol Lowering Drugs)

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.

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

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.

Low Cholesterol And Cancer Risk

A provocative press release crossed my desk today, “Study Finds Association Between Low Cholesterol Levels and Cancer” with subtitle: “Benefits of Statin Therapy Outweigh Small Risk.”  Well that’s fairly terrifying, isn’t it?  It sounds as if they’re saying that taking a statin (like lipitor or zocor) is good for your heart but might carry with it the “small” risk of developing cancer.

First of all, let me assure you that this is a gross misinterpretation of the metanalysis.  The authors themselves never postulated a cause and effect between statins and cancer, and in fact did all they could to avoid drawing this conclusion.  They merely observed that there was a slight trend towards higher cancer rates among people with low LDL cholesterol.

There are two very good explanations for the higher cancer rates in people with low cholesterol:

1. Everyone knows that “unexplained weight loss” is an ominous sign.  Often times a patient’s first clue that they have cancer is sudden weight loss – since cancer has a voracious appetite and steals nutrients from the rest of the body.  When people lose weight, their cholesterols decrease.  So it’s possible that low LDL cholesterol is really just a surrogate marker for those who already have very early stages of cancer that have not yet been detected otherwise.

2.  Statins are well known to reduce cholesterol and the atherosclerotic plaques that put people at risk for heart attacks and strokes.  Lower cholesterol levels can reduce overall mortality risk/year by 30%, and so people live longer when they have lower cholesterol levels.  People who live longer extend their opportunity to develop cancer.  And so lower cholesterol levels inadvertently raise your cancer risk simply because they may extend your life.

Why else do I think the link between cancer and statins is faulty?  Because the observed increase in cancer rates was in ALL cancer types – the genetics of cancer is so complex, and the reasons why certain cell types begin to divide in an uncontrolled manner is so diverse, that it’s hard to imagine any possible trigger could stimulate all cells to become cancerous.  Also, most cancers develop very slowly, and the 5 year window in which the authors observed people taking statins and developing cancers is too short to be a cause and effect.  And finally, previous statin safety studies showed no link between them and the development of any form of cancer.

The Journal of the American College of Cardiology admits in an
accompanying editorial, “In the 5 years that we have been stewards of
the Journal, no other manuscript has stimulated such intense scrutiny
or discussion.”  Do I think they should have published this study?  Yes – but to me the most interesting question out of all of this is: could cholesterol screening be used for early cancer detection?  If an extra low LDL is observed, maybe that should prompt some additional investigations to rule out occult malignancies?

Obviously, more studies are needed to determine the potential validity of such an approach… but for now, there is absolutely no reason (based on this study) to cease statin therapy for fear of developing cancer.  Hope that allays some fears!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Drugs: Oldies Can Be Goodies

Just because a drug is new, doesn’t mean it’s more
effective.  A recent
article
published in the Annals of Internal Medicine demonstrated that older
diabetes medications may be equally effective as some of the newer, more
expensive drugs.

Now this comes as no surprise to physicians, who know very
well that some of our “old standby” meds work just as well as their newer, more
expensive versions.

For example:

For mild to moderate acne treatment, good old Clearasil may be all you need.
A study
published in the Lancet found that over-the-counter topical treatments (benzoyl
peroxide based) worked just as well as more expensive new oral antibiotics
(including minocycline).

For mild to moderately elevated cholesterol, there doesn’t appear to be much
advantage
to taking a newer statin than on older one.  The cost difference may be as much as ten
times more, for small gains (if any).
For example, mevacor (lovastatin) is as inexpensive as 0.24 cents/pill
while lipitor (atorvastatin) can run up to $2.54/pill.

Dr.
Charlie Smith
, former president of the American Board of Family Practice,
recommends these very cost effective medications to his patients as needed:

Hydrochlorothiazide for hypertension (from 8 cents to 20 cents/pill)

Bactrim (trimethoprim/sulfamethoxisole) for urinary tract infections (15
cents/pill).

Ibuprofen for pain relief/arthritis (about 7 cents/pill).

So consumer beware – those medications that you see in all the TV ads may not actually provide substantial benefits over older, less expensive drugs.  Be sure
to ask your doctor if a less expensive medication might be appropriate for you… or
better yet, healthy lifestyle changes can sometimes make the difference between needing
a medication and not needing it at all.

*Drug prices may vary.

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

High Blood Pressure and Hidden Salt

In a charming news article, the BBC reports that the British Sandwich Association is concerned about high salt levels in national fare.  If you have high blood pressure, there is now new evidence that avoiding soup and potato chips will not be sufficient in curbing your salt intake.  Yes, even the humble sandwich can be a good hiding place for sodium.  But this article is even more whimsical than informative.

First of all, I think it’s terribly funny that the “British Sandwich Association” actually exists – and that its public health warnings are taken very seriously.  Second, I think that the contents of common British sandwiches are somewhat disturbing: a “prawn mayonnaise” sandwich lacks a certain appeal in my mind.  And the fact that this variety of sandwich was selected as a representative example of a typical sandwich is also amusing.

And finally, the website for the British Sandwich Association is hilarious.  Check out part of their mission statement:

“To safeguard the integrity of the sandwich market by setting standards
for sandwich making, by encouraging excellence in sandwich making and
by encouraging the development of the industry in terms of skills,
innovation and overall market development.”

And the BBC includes this very astute quote from the organization’s director:

“Sandwiches involve the assembly of ingredients,” said Jim Winship, director of the organisation.   “The fact is that the salt is already in the ingredients…”

Well, I think the take home message here is that if you have high blood pressure or are on a low salt diet, remember that sandwiches often contain very high sodium levels.  The message between the lines is that the British are inherently funny and have bizarre taste in food.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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