Tag Archives: cholesterol

Panel recommends cholesterol testing for all kids

In June I told you in this blog that “all children should be screened for high cholesterol when they’re 9 to 11 years old according to new guidelines from the National Lipid Association (NLA).” I mentioned then that there would be more guidelines “in the fall. So, stay tuned.” Well now those new recommendations are out: Continue reading

Cholesterol-lowering foods beat low fat diet

A dietary intervention study of cholesterol-lowering foods with either two or seven counseling sessions significantly lowered LDL cholesterol (the lethal or bad cholesterol) compared with a control diet emphasizing reduced saturated fat consumption. The results between the groups receiving two versus seven counseling sessions were not significantly different. The bottom line? Cholesterol lowering foods are more highly healthy than a low fat diet. Continue reading

Red yeast rice products NOT recommended for high cholesterol

The Chicago Tribune “Julie’s Health Club” blog reported that “some red yeast rice products have been shown to lower cholesterol levels as effectively as moderate doses of statin drugs.” However, “the supplement isn’t quite ‘ready for primetime,’ according to researchers who found that 12 over-the-counter red yeast products had strikingly inconsistent amounts of active ingredients.”

The research, “published in the current issue of the Archives of Internal Medicine, also showed that four of the 12 products (one third of the sample) contained citrinin, a contaminant that is toxic to kidneys of animals.” WebMD and MedPage Today also covered the story.

It for this reason that I do NOT recommend anyone take red yeast rice. In addition to the above study, a recent analysis by ConsumerLab found red yeast rice products varied sharply in their potency, and some were contaminated with a toxic byproduct called citrinin.

This is not true of the prescription statins, which are regulated by the FDA. And, with prescription drugs you can be sure:

  • There are no contaminants,
  • The pills are the same from bottle to bottle,
  • The pills can be absorbed into your body, and
  • The pills are made with an approved manufacturing process.

Unfortunately, in the U.S., the same is not true of most supplements.

Furthermore, generic statins are available at most pharmacies for $4 for a month’s supply or $10 for a three-month’s supply. That’s much, much less expensive that red yeast rice supplements.

However, there is one protection for the American consumer, when it comes to dietary supplements – and that is to see if it has been evaluated by an independent testing lab. And the lab that has tested more supplements than any other is ConsumerLab. Check them out.

High cholesterol in youth may increase heart risks later in life

For the last couple of years, I’ve been offering my adolescent patients the option of checking their lipid panels, especially if they are overweight or obese. Now, new research is showing the wisdom of this approach. The Wall Street Journal reports that research published in the Annals of Family Medicine suggests that even younger people should pay attention to their cholesterol levels, being that they may have an impact on health later in life.

The Los Angeles Times “Booster Shots” blog reported that researchers “analyzed data from 3,258 men and women who have been tracked by the CARDIA , or Coronary Artery Risk Development in Young Adults, study for the last 20 years and were ages 18 to 30 at the start of the study.”

The investigators “found that participants with histories of high levels of the ‘bad’ LDL cholesterol were five and a half times as likely to have a buildup of calcium in their coronary arteries … than those who had optimal LDL cholesterol levels.”

The researchers also found that “rates of coronary calcium buildup were also higher in those who had suboptimal levels of the so-called ‘good’ cholesterol, high density lipoprotein, or HDL cholesterol, although this association was weaker.”

The New York Times reports in Vital Signs that “young adults tend to be notoriously lax about preventive health care, and cholesterol screening is no exception,” according to the new  study.

Barely “half of all young men and women are screened for high LDL, the so-called bad cholesterol,” according to the study by the CDC’s Elena Kuklina and others.

The research was based on “analysis of data on 2,587 young adults — including men aged 20 to 35 and women aged 20 to 45.”

Kuklina said “young adults should be screened, because heart disease is a chronic condition that can begin damaging blood vessels at an early age.”

In our practice we’ve certainly found scores of kids with surprisingly abnormal lipid panels. I, my patients, and their parents are certainly glad we did.

Nuts may help lower cholesterol levels

According to a report in the Wall Street Journal research published in the Archives of Internal Medicine suggests that nuts may help lower cholesterol levels.

HealthDay reported that investigators “pooled data on 583 men and women who had participated in 25 nut consumption trials.”

“Patients in the trials ate an average of 67 grams, or about 2.4 ounces, of nuts daily,” WebMD reported. While MedPage Today reported that the researchers found that “eating an average of 67 grams of nuts a day (2.4 ounces) reduced total cholesterol by 5.9% and LDL cholesterol by 7.4%.”

The bottom line, a couple of ounces of nuts per day may be heart healthy and highly healthy.

Should Cholesterol Drugs Be Used By Those Without High Cholesterol?

Some experts say statins help healthier people, but others worry about risks. So, when the U.S. Food and Drug Administration (FDA) approved the use of the cholesterol-lowering statin drug Crestor for some people with normal cholesterol levels, cardiologist Dr. Steven E. Nissen cheered the decision. But, not everyone did. Here are the details in a report from HealthDay News:

“You have to go with the scientific evidence,” said Nissen, who is chairman of cardiovascular medicine at the Cleveland Clinic. “A clinical trial was done and there was a substantial reduction in morbidity and mortality in people treated with this drug.”

But Dr. Mark A. Hlatky, a professor of health research and policy and medicine at Stanford University, has expressed doubts about the FDA move. He worries that more people will rely on a pill rather than diet and exercise to cut their heart risk, and also points to studies linking statins such as Crestor to muscle troubles and even diabetes.

“I haven’t seen anything that changes my mind about that,” Hlatky said.

So, will millions of healthy Americans soon join the millions of less-than-healthy people who already take these blockbuster drugs?

The FDA’s February approval of expanded use of rosuvastatin (Crestor) was based on results of the JUPITER study, which involved more than 18,000 people and was financed by the drug’s maker, AstraZeneca.

People in the trial who took the drug for an average of 1.9 years had a 44 percent lower risk of heart attack, stroke and other cardiovascular problems compared to those who took a placebo — results so outstanding that the trial was cut short.

Based on JUPITER, an FDA advisory committee voted 12 to 4 in December to approve widened use of the drug.

The people in the trial included men over 50 and women over 60 with normal or near-normal cholesterol levels.

However, these individuals did have high levels of C-reactive protein, a marker of inflammation that has also been linked to cardiovascular problems. They also had at least one other heart risk factor, such as obesity or high blood pressure.

For that specific group, Crestor makes sense, Nissen said. “Over a five-year period of time, you prevent one death or minor stroke for every 25 people treated,” he noted.

Whether or not others with normal cholesterol should take Crestor or another statin remains unclear. “Not everyone with normal cholesterol should be treated,” Nissen said. “You should give it to people with a high enough risk.”

And he added that the results applied only to Crestor. Other popular statins include Lipitor, Pravachol and Zocor, as well as some generic versions.

Those statins might not produce the same benefits, Nissen said. “Statins differ from each other in terms of potency,” Nissen said.

Crestor, which is available only in a more expensive brand-name form, is toward the top of the list in terms of potency, he noted, while generic drugs such as simvastatin (Zocor) and pravastatin (Pravachol) have much less powerful effects.

“For patients who need a lot of cholesterol reduction, I use the most powerful drug,” Nissen said. “If I can get a patient there with a generic drug, of course I use a generic drug.”

But Hlatky has his doubts about the advisability of widening statins’ reach. He said he’s reluctant to have people at cardiovascular risk pop a pill rather than change the lifestyle factors that put them in trouble in the first place.

“My view has always been that you start with the basics and do the simple things first before you go to drugs,” Hlatky said. “Lots of people are not doing the sensible things. They’re not eating the right diet, they’re not exercising, they’re still smoking. Most of the people in the JUPITER trial were smack in the middle of that group.”

So Hlatky says he might still prescribe a statin for someone in that group, “but I would have an informed conversation about the long-term risks and benefits and what you need to do to reduce the risks.”

“It is so much easier to prescribe a drug than to change behavior, and that is my worry,” Hlatky said. “We’re heading down that road. Cardiovascular risk prevention is moving in the wrong direction.”

He’s also worried about exposing more people to the rare but still possible side effects that come with statins. The drugs can cause myalgia — severe muscle pain — and a recent study published in the British journal The Lancet found a 9 percent increase in diabetes incidence among people taking statins.

But Nissen believes the benefits of expanded use of Crestor outweigh possible risks. The study that found an increased incidence of diabetes did not find that it was accompanied by any increase in cardiovascular problems and deaths, he noted.

“The is one example where the FDA got it exactly right,” Nissen said.

And, from my perspective, I agree.

Obese Children Twice as Likely to Die Young

In my Amazon.com best-selling book, SuperSized Kids: How to protect your child from the obesity threat, I predicted that if we did not stem the epidemic of childhood obesity, that our children could become the first generation in American history to have a shorter life expectancy than their parents.

Now, the New York Times is reporting on a study published in the New England Journal of Medicine “that tracked thousands of children through adulthood found the heaviest youngsters were more than twice as likely as the thinnest to die prematurely, before age 55, of illness or a self-inflicted injury.”

While “youngsters with … pre-diabetes were at almost double the risk of dying before 55, and those with high blood pressure were at some increased risk,” it was obesity that was “most closely associated with an early death, researchers said.”

These “data come from a National Institutes of Health study that began in 1965,” USA Today reports.

After tracking “4,857 American Indian children in Arizona for an average of 24 years,” investigators found that “children who were the heaviest – the top fourth – were more than twice as likely to die early from natural causes, such as alcoholic liver disease, cardiovascular disease, infections, cancer, and diabetes, as children whose weight put them in the lowest quarter of the population.”

Bloomberg News reports, “The number of overweight and obese children has tripled since 1980, according to the US Centers for Disease Control and Prevention.”

Approximately “17 percent of US children ages two to 19 years old are considered obese and almost 12 percent are considered the heaviest kids, according to a CDC study released in January.”

The current study’s “findings detail the ‘serious health consequences’ that children might face as they get older, lead study author Paul Franks said.”

WebMD reported, “Death rates from natural causes among children in the highest group of glucose intolerance (a risk factor for developing diabetes) were 73% higher than among the children in the lowest group of glucose intolerance, the researchers found.”

While “no substantial links were found between cholesterol levels and premature deaths,” the study authors “did find that high blood pressure in childhood raised the risk of premature death from natural causes by about 1.5 times.”

HeartWire reported that an accompanying editorial “notes that the causes of obesity and diabetes appear to be rooted in culture – inactivity and large portion sizes of calorie-dense fast food – and that fighting these diseases with ‘clinical and adult-based approaches’ is akin to ‘pasting a small bandage on a gaping wound.'”

The new study is timely and important, says Marc Jacobson, MD, a Great Neck, N.Y., pediatrician who specializes in caring for children with obesity and cholesterol problems. “It gives us more hard data about the long-term effects of adolescent obesity,” he says.

Jacobson serves on the American Academy of Pediatrics’ Obesity Leadership Workgroup. The Academy recommends that BMI be measured in all children and that those with a BMI above the 85th percentile be helped to get it below the 85th percentile, which is considered a healthy weight, he says.

The American Academy of Pediatrics has a tool parents can use called 5210, Jacobson says. “It’s used to prevent childhood obesity.” It stands for:

  • 5 servings of fruits and vegetables daily
  • 2 hours or less of television viewing daily
  • 1 hour of exercise daily
  • 0 or nearly zero sugar-sweetened beverages daily

In the editorial accompanying the new study, Edward W. Gregg, PhD, of the DC, notes that the Pima Indians studied in the research are sometimes viewed as not representative of the U.S. population because their risk of diabetes is especially high.

But, he points out that 4% of the participants in the study had impaired glucose tolerance, a percentage similar to the 3% of U.S. teens overall who have the condition. And the condition affects 9.5% of obese teens, he says.

So, what’s a family to do? What if you are your children are overweight or obese? I have a number of resources to assist you:

  • My Amazon.com best-selling book, SuperSized Kids: How to protect your child from the obesity threatYou can order the book here, read the Table of Contents here, or read the first chapter here.
  • My SuperSized Kids Web site, that you can find here.
  • My SuperSized Kids assessment tool that will help you evaluate the activity and nutrition habits of your family. That assessment tool is available for free here.
  • My 8-Week Family Fitness Plan (SuperSized Kids 8-Week Plan), available for freehere.

One in five US teens may have abnormal lipid levels — most related to overweight or obesity

The Washington Post reports that “one out of every five US teenagers has a cholesterol level that increases the risk of heart disease,” according to a new study published in the CDC’s Morbidity and Mortality Weekly Report.

For “the study … researchers analyzed data collected from 3,125 youths through the National Health and Nutrition Examination Survey.” The data indicated that “20.3 percent had abnormal ‘blood lipid’ levels.”

Bloomberg News reports that “obese children were at the highest danger of abnormal levels, with 43 percent testing outside the recommended ranges.”

Ashleigh May, an epidemiologist at the CDC’s division of heart disease and stroke prevention, said, “Parents should inquire about whether their child is eligible for this lipid screening, especially if their child is overweight or obese.”

MedPage Today reported that “an unsigned commentary by MMWR’s editors noted that ‘untreated abnormal lipid levels in childhood and adolescence are linked to increased risk for cardiovascular disease in adulthood,’ but they stopped short of endorsing routine lipid testing for adolescents.”

MedPage pointed out that “the American Academy of Pediatrics recommends screening youths with specific risk factors such as overweight and family history.”

Now, since most children with abnormal lipids also are overweight or obese, you’ll be pleased to learn that I have a number of resources to help families deal with these issues in positive and constructive ways:

  • My Amazon.com best-selling book, SuperSized Kids: How to protect your child from the obesity threatYou can order the book here, read the Table of Contents here, or read the first chapter here.
  • My SuperSized Kids Web site, that you can find here.
  • My SuperSized Kids assessment tool that will help you evaluate the activity and nutrition habits of your family. That assessment tool is available for free here.
  • My 8-Week Family Fitness Plan (SuperSized Kids 8-Week Plan), available for freehere.

Readers ask about my response to the Zetia / Vytorin study that is all over the news

Cholesterol Drug Controversy Continues

Some of you are wondering about my response to this news. First of all, you should know that I’m on Vytorin. My doctor had recommended a statin, along with omega-3 fatty acids for my increasing triglycerides and decreasing LDL (lethal) cholesterol. When my cholesterol particle counts (we don’t just follow my lipid profile) didn’t meet goal, my doctor added Zetia (using the statin and Zetia combination drug of Vytorin). Voilà, my particle counts are way normal.

Does this new information change my view about the reasonableness of adding either nyacin or Zetia to a statin as add-on drugs? Absolutely not. You can read my previous blogs on Zetia here:

In the meantime, for the many doctors who read this blog, I’ve solicited the opinion of a friend and internationally-recognized lipidologist, Tom Dayspring, MD. Here’s his response to the newest study data. It’s a long, and complex read, but well worth it for medical professionals:

By now you have likely heard something about the ARBITER-6 HALTS trial which was just presented at the AHA and published in the New England Journal of Medicine. Basically this is a trial designed to show what happens to carotid intima–media thickness (IMT) when either Zetia or Niaspan is added to a long term statin use.

For those who do not know, I am a consultant and National Speaker for both Abbott Labs and Merck (Schering Plough). I educate professionals all the time about aggressive use of lipid drugs to achieve goals.

I believe Niaspan, Zetia, fenofibrate, Trilipix, and Lovaza are grossly under prescribed. They are all potential “statin-helper” drugs.

Without outcome data (data on heart attacks, strokes, deaths), no one can ever state one combination is superior to another.

Readers of my newsletters know by now that statins have serious residual risk in all their trials and only get a minority of patients to apoB or LDL Particle Count (LDL-P) goal. Per all guidelines combination therapy is indicated to achieve goal.

There is zero Level One outcome data with any of the potentially available combination therapies that are out there right now.

So the only sane way to know what drugs to add to a statin is will the combo help me get to lipid goals (non-HDL-C) or lipoprotein goals like apoB or LDL-P and perhaps an emerging goal – HDL-P (not always the same thing as HDL-C)).

I happen to very much like both Niaspan and Zetia as wonderful statin-helping therapies.

I personally take 2000 mg of Niaspan as well as Zetia 10 mg every day (along with TriCor) along with once weekly statin (because of myalgia). And, I prescribe Zetia and Niaspan a lot in my practice to help achieve goal.

Based on multiple existing angiographic trials and now the ARBITER-6 HALTS trial it is my belief that if you have coronary heart disease (CHD), I want to know why Niaspan, unless it is not tolerated, is not part of your regimen to help achieve goal (except for unusual circumstances I never use niacin or Zetia monotherapy).

The ARBITER-6 HALTS trial was small, open-label (impossible to do a blinded trial with niacin) randomized trial enrolled CHD patients (with high or very high risk) who were on a statin for several years (mostly atorvastatin with some simvastatin) at or near LDL-C goal (all < 100 mg/dL).

They then received either Niaspan (extended release niacin) titrated to 2000 mg (a dose rarely used in the real world) or Zetia (ezetimibe) 10 mg daily. As expected there were more Niaspan dropouts due to drug side effects in the trial compared to Zetia.

The endpoint was change in carotid IMT over a year.

Unfortunately the trial was stopped prematurely, for no good reasons (both of the editorialists [see the editorials here and here] in the NEJM and the discussants at the AHA meeting agreed on that). Premature stoppage likely means whatever findings occurred are over-exaggerated.

Furthermore, the morons in the press are running around telling people they can take an over the counter vitamin for CHD. Niacin at 2000 mg or more mg per day is way beyond the vitamin dosage: it is a major pharmacological dose of a vitamin B3 and cannot be considered a vitamin at that dose and certainly has issues that must be followed.

Patients in the study had at goal or near goal LDL-C and borderline low HDL-C at the lower end of normal (remember baseline HDL-C was assayed while on a statin – not in a drug naive state).

Tragically the author did not see fit to measure the far more important parameters apoB or LDL-P or apoA-I or HDL-P. That is a mind boggling oversight in 2009 and it also makes it much more difficult to truly interpret what are the benefits of statin/Zetia (Vytorin) or statin/Niaspan (Simcor).

Most of these patients were on statins for over 5 years and thus their carotids have many years of statin therapy. Over the very short 14 month period of this trial the carotid IMT (CMIT) changes regressed on Niaspan/statin while statin/Zetia caused non-progression or miniscule regression (just like Crestor, a proven outcome therapy, did in METEOR).

Thus neither combination therapy failed, but Niaspan/statin induced what certainly seem to be more favorable changes than the statin/Zetia.

However there is no data that event reduction would be any different in patients with no progression versus regression. So until we have outcome trials, no one can conclude which combo therapy is in reality the best therapy.

Both editorialists and all discussants at AHA made that clear. However, let’s be also be very clear that based on CIMT changes statin/Niaspan was the winner.

However, because of the lack of data correlating therapy-produced, precise imaging changes to outcomes, there are no guidelines advising us to judge the efficacy of our drugs by performing repeat imaging procedures (including IMT).

Does everyone remember that estrogen, raloxifene, Fosamax and torcetrapib all have positive CIMT data and NONE have been shown to reduce cerebrovascular disease (CVD) events? Indeed both estrogen and torcetrapib also raise HDL-C.

Statin data on IMT changes are all over the map (positive and negative) yet all statins reduce outcomes. There does not seem to be much linkage. Pravachol reduces outcomes in its trials but was associated with plaque progression in an IVUS study (REVERSAL).

The lipids concentrations and presumably lipoprotein were beneficially altered with the addition of either Zetia or Niaspan. Zetia helped LDL-C more than niacin and niacin helped TG and HDL-C more than Zetia (no surprise there). Both drugs helped non-HDL-C.

My guess is the LDL-P (apoB) was fairly well controlled by the several years of statin use in this trial and both Zetia and Niacin further improved that crucial parameter (LDL-P or apoB). My guess is also that niacin improved apoA-I and total HDL-P and the Zetia did not. That would likely be a benefit in the Niaspan column.

My conclusions:

  • We grossly under treat our patients.
  • Statin monotherapy, usually nontitrated is the routine therapy in the US.
  • Stents, strokes, bypass and deaths are way too high despite statin monotherapy.
  • We desperately need to get more aggressive to achieve all goals, especially lipoprotein goals.

Want to help lower apoB (LDL-P):

  • Use statins — if not at goal add Zetia, Welchol, or Niacin in no particular order although if there are not TG or HDL issues, I prefer Zetia first because of ease of use.
  • However if HDL-P (HDL-C) is low in the face of an elevated apoB or LDL-P then Niacin becomes my first add on (which is the exact recommendation made by ACC and ADD position statement published last year).
  • If the TG are an issue (> 200 mg/dL) or TG/HDL axis is abnormal then a fibrate, niacin (or high dose or omega-3) is the likely best choice.

So, if I take a drug like Niaspan and can help a statin achieve better apoB levels and raise HDL-P levels, I think I have a great add on. Simcor would save be a copay, but Crestor/Niaspan would be the more potent therapy.

The ARBITER-6 HALTS trial certainly supports Niaspan/statin use. I prescribe Niaspan as they did in the study: get all patients to 2000 mg ASAP. I suggest you do the same. You cannot expect lower doses of Niaspan to achieve these results.

With proper advice, and perseverance Niaspan use is easier done than commonly believed. Abbott also offers a nice program to help patients properly take Niaspan. Talk to your reps.

This study does not change the fact that apoB (LDL-P) reduction is the primary goal, but it enforces the belief that raising HDL-P should be the secondary goal (by the way, fibrates raise HDL-P more so than niacin, yet fibrates, because of what they do to LDL size, do not raise HDL-C anywhere near what niacin does).  This is one reason HDL-P is more informative than HDL-C.

If a patient on statin/Zetia is still not at LDL-P goals of therapy, Niaspan can help even if the HDL-C is not low. Also, if I have a patient on statin/Niaspan and LDL-P is not at goal I add Zetia. There is published data that statin/Zetia/Niaspan is a great lipid modulating triple therapy.

Bottom line:

  • we all need to use a lot more Niaspan (all CHD patients should be on it along with whatever else is needed to get to goal).
  • No one needs to stop Zetia in anyone and no one needs to be afraid of using Zetia to help achieve goal.
  • For your Vytorin users: if HDL-P is not normal or LDL-P is still high: please add Niaspan AND PLEASE TITRATE IT TO TWO GRAMS.

I want to conclude some of the what I consider outrageous statements made in the paper by the author.

  1. Is it plausible that Zetia is harmful to atherosclerosis: that is the conclusion by the author speculating on lipid issues that I do not believe have any support? The paper hints Zetia impairs reverse cholesterol transport. I can supply several studies show it improves RCT (start with Arterioscler Thromb Vasc Biol.
2008;27:1296-1297).  I also hate to remind everyone: a serum HDL-C has no relationship what so ever to the dynamic process called reverse cholesterol transport. Macrophage RCT (removing cholesterol from the arterial wall) has no influence on serum HDL-C levels. Niacin raises HDL-C by increasing apoA-I production, inducing hepatic lipidation of HDLs, reducing CETP activity, inhibiting hepatic lipase (thus making HDLs large) and reducing the apoA-I beta synthase hepatic holoparticle receptor.
  2. ACAT (the enzyme that esterifies free cholesterol into cholesteryl ester) inhibition is bad and Zetia is thus bad because it reduces ACAT. ACAT inhibitors, which have failed in clinical trials prevent esterification of cholesterol and the free cholesterol accumulates in macrophages. Zetia reduces ACAT activity and expression because by reducing cholesterol delivery (absorption) ACAT downregulates. There is no cellular cholesterol accumulation on Zetia. In the study quoted, the dose of Zetia that impacted ACAT, was infinitely larger than we use to treat lipids.
  3. The author states Zetia affects SRB1 and thus impairs RCT. The study referenced was looking at SRB1 in intestinal cells has nothing to do with reverse cholesterol transport. Niacin inhibits ApoA-I beta chain synthase the hepatic holoparticle (HDL catabolism) receptor which decreases hepatic uptake of HDL trafficked cholesterol and potentially decreases RCT. Yet niacin sure works. Statins downregulate ABCA1 the main HDL lipidation enzyme involved with macrophage RCT yet they work.
  4. Amazing the NEJM published a nonsensical post hoc analysis showing too much LDL-C lowering with ezetimibe worsens CIMT. This trial is not empowered to examine such an endpoint in a univariate analysis. Shame on the NEJM and their reviewers for allowing such speculation. This has outraged many respected lipidologists. The author was taken to task by the discussants on the podium for this type of analysis.
  5. Implying that Zetia increased CV endpoints in a trial that has no such power to do so is the worst kind of  fear mongering analysis and no one should pay any attention to such a statement. The author again was taken to task big time by the discussants on the podium for stating such a thing. The main discussant John Kastelein firmly stated that mortality data has NO MEANING. Shame on the NEJM for letting such statements appear.

In conclusions: FACTS:

  1. There is no outcome data for Zetia of any kind.
  2. There is no level one evidence for Niacin: there is secondary endpoint data from CDP.
  3. There is no outcome data relating what a drug does to HDL-C benefits CVD outcomes, but there is level 2 evidence that raising HDL-P is beneficial (see VA-HIT).
  4. There is no data relating specific drug induced imaging benefits (including IMT) to CV outcome benefit. Crestor, a drug proven to significantly reduce CV outcomes failed to induce regression in a big CIMT trial (METEOR) but rather inhibited progression (exactly what statin/ezetimibe did in this trial. Yet in an angiographic trial regression occurred with Crestor.
  5. Fact: every guideline wants you to get to lipid/lipoprotein goal using lifestyle and FDA approved drugs. Statins first line if TG are < 500 mg/dL. In patients with cardiometabolic risk, niacin is the preferred first add on drug (ADA/ACC consensus statement).


  • NIASPAN is a great statin helper drug and needs to be prescribed much more frequently than it is.
  • Zetia is a great statin helper drug and needs to be prescribed much more frequently.
  • No one should be stopping Zetia, no one should be afraid to use Zetia to get to goal and for sure we need to use a lot more Niaspan at 2000 mg.
  • Guess what: I am not stopping my Zetia – I surely and happy to continue my Niaspan and I’d ask you all to review the great John Guyton study: Lipid-Altering Efficacy and
”Safety of Ezetimibe/Simvastatin coadministered With Extended-Release Niacin in Patients With Type IIa or Type IIb Hyperlipidemia: (J Am Coll Cardiol 2008;51:1564–72.

Conclusion: Combination treatment with E/S plus N showed superior lipid-altering efficacy compared with N or E/S in type IIa or IIb hyperlipidemia patients and was generally well tolerated aside from N-associated flushing. This combination offers an effective, broad, lipid-altering therapy with improvements in lipid effects beyond LDL-C in these patients.

Happy Lipiding,

Tom Dayspring, MD

Guys, keeping your cholesterol low may reduce your prostate cancer risk

There’s good news for men concerned about developing prostate cancer. The AP reports, “Men may protect more than their hearts if they keep cholesterol in line: Their chances of getting aggressive prostate cancer may be lower.” Want to learn more? Then, read on as scientists at two institutions have detailed the research that led them to that conclusion in Cancer Epidemiology Biomarkers & Prevention.

According to the AP report, even though the papers “are not definitive and have some weaknesses,” they do “fit with plenty of other science suggesting that limiting fats in the bloodstream can lessen cancer risk.”

HealthDay reported that NCI investigators reviewed “data from a study that has followed more than 29,000 Finnish men for 18 years,” finding that “cholesterol levels below the generally recommended 200 milligrams per deciliter were associated with an 18 percent higher overall risk of cancer.”

Two studies looked at cholesterol in cancer finding that low cholesterol is a symptom rather than a cause and that low cholesterol may actually lower a man’s risk of high-grade prostate cancer.

In the first study, researchers observed over 29,000 men for 18 years for cancer and found no association unless they included men who were diagnosed right away after enrolling in the trial.

These men likely already had cancer and their low cholesterol was an effect and not a cause, since all the other men didn’t develop cancers at a rate different from men with normal or high cholesterol.

The second study found an association between low cholesterol and lower than average risk for high-grade prostate cancer, however we need to see the results of a clinical trial looking at the effects of lowering cholesterol on cancer risk before there will be recommendations for drugs like statins to be used preventively.

An editorial in same issue of Cancer Epidemiology, Biomarkers & Prevention concluded, “Results from the two analyses of cholesterol and risk of cancer published in this issue . . . clearly show that low total cholesterol is unlikely to increase risk of cancer.”

The editorial also makes this interesting observation: “If results of such observational studies support the hypothesis that low cholesterol inhibits prostate cancer progression, then it would raise the question of whether prostate cancer patients choosing active surveillance, rather than immediate treatment, could reduce their risk of disease progression by using statins or other cholesterol lowering drugs. This question, however, would need to be answered by a randomized trial.”

So, the bottom line?

Guys, get a lipid profile and if it’s abnormal do what you must do to get it normal — whether that’s changing your nutrition, increasing your physical activity, or using cholesterol lowering drugs.

Ladies, get the guys you love to have a lipid profile. If it’s abnormal, follow the advice above.

New Guidelines Suggest Cholesterol Meds for Kids

According to Fox News, for the first time, an influential doctors group is recommending that some children as young as 8 be given cholesterol-fighting drugs to ward off future heart problems. It is the strongest guidance ever given by the American Academy of Pediatrics, which released its new guidelines Monday. 

My Take? Continue reading

“The Russert Effect”: Docs Report Surge in Appointments

ABC News is reporting a phenomena that family physicians around the country are reporting to me: Tim Russert’s death Friday from sudden cardiac arrest may have hit a nerve deeper than sadness.

Russert’s death may have lead some to fear for their own seemingly healthy bodies, or the health of a loved one – and doctors are seeing the effects. Calls are up dramatically for exams for middle aged men. Continue reading

Erectile Dysfunction an Indicator of Men’s Health

HealthDay News is reporting a story saying that erectile dysfunction could be an indicator of testosterone deficiency and the metabolic syndrome, a set of factors that may indicate an increased risk of heart and vascular disease and type 2 diabetes.

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