The balance between HDL – the so – called “Good or Happy” cholesterol and LDL – the so – called “Lousy” cholesterol is often used as a way to evaluate one’s risk of developing clogged arteries. However, some people still have heart attacks or strokes despite seemingly ideal levels of of these fats in their blood, while others with low HDL and high LDL levels seem to do just fine.
So researchers have been searching for different kinds of blood tests to better define one’s risk of getting clogged arteries and better treatments for those at risk. One potential way to better define one’s risk for heart attack or stroke is the use of blood tests that look at more than just HDL, LDL, and triglycerides. In our practice we also are integrating newer tests with names such as LDL particle number, HDL Map, and LDL pattern, just to name a few.
The mainstay of cholesterol drug treatment, the class of drugs known as statins, while safe and effective for most, can be difficult for some people to tolerate because of muscle pains or even weakness. Niacin, which has been around for a long time and can increase the good HDL, has yet to show that it is beneficial when it comes to lowering one’s risk of arteriosclerosis. Similarly, drugs known as fibrates (tricor, lopid) have struggled to show they reduce arteriosclerosis. Ditto for Zetia. New drugs that raise HDL have not come to market because of safety concerns.
The one class of drugs that may soon reach the market are the PCSK9 inhibitor drugs. These drugs work on something called LDL Receptor Metabolism and can lower “lousy” cholesterol levels dramatically. They have the potential to be game changers in the treatment of high cholesterol and to manage those who already have clogged arteries by dropping LDL levels to previously unimaginably low levels. One drawback: they would need to be given by injection, but perhaps once a month would be sufficient.
Is lowering one’s cholesterol so low safe? The PCSK9 inhibitor drugs are modeled on the fact that a few people have been discovered with genetic variations in their PCSK9 genes that naturally lower their LDL levels from a typical 130 or so to only 15! These people seem to be otherwise healthy and without any signs of arteriosclerosis. With cholesterol levels pushed down that low, it is is conceivable that this class of drugs might not only slow down arteriosclerosis, as do present statin drugs, but might actually reverse it. Nonetheless, if approved by the FDA, it may well take years of experience to know for sure that the drugs don’t have unintended consequences. More than three decades after approval, we are still learning about the pros and some of the cons of statins. In the meantime lifestyle changes such as weight loss and increased exercise as taught in our multidisciplinary weight loss program can make a big difference for many people in both their cholesterol numbers and their cardiovascular risks, and statins will remain an important treatment for some time to come.
by Dr Ed Taubman Primary Care Physician Olney MD 301-774-5400
Once Again Voted Top Doctor Washingtonian Magazine
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