About a year ago, the American Heart Association released new cholesterol management guidelines. These guidelines changed how we practitioners should deal with cholesterol evaluation and management almost to a revolutionary degree. They are a BIG departure from past thinking. For example, under the old system, we practitioners were supposed to follow cholesterol labs. We were supposed to get LDL levels down below 100. Not anymore! In fact, under the new guidelines, once you have started someone on therapy, you really don’t have to check their cholesterol ever again! Really!
Also, the new guidelines say that there is basically only one therapy for almost all lipid patients: statins. According to the new guidelines, we should get rid of all other lipid therapies. Niacin? Throw it away. Gemfibrozil and fish oil? Get rid of them.
What about triglycerides? The new guidelines say that you should only treat hypertriglyceridemia with medications when the triglyceride level is greater than 1000mg/d. Holy cow, 1000! Where did that come from?
This document is almost revolutionary in its sweeping changes. It makes treating hyperlipidemia so very much easier. In my opinion, all correctional practitioners and nurses involved in chronic care clinics should know the new guidelines. If you have not already done so, you need to re-write your lipid protocol.Continue reading →
The Wall Street Journal published a little debate between two prominent physicians about whether statins are appropriately used to prevent heart disease in patients with no history of heart disease.
This is an important question for jails and prisons partly because of the costs of these medications. If inmates without heart disease are getting no benefit from these drugs, why should we prescribe them?
You’ve got hyperlipidemia!
My understanding of the hard data behind statins is this:
1. People who have known coronary heart disease (they have had an MI, say, or a stent) should normally be on a statin no matter what their cholesterol values are. Statins work in this population both for those with normal cholesterol levels and those with high cholesterol. There is speculation that statins work in this group not by lowering cholesterol, but by some other mechanism.
2. The big studies on statin use in people without coronary artery disease have shown no benefit for these populations: Women and patients over 70 years old.
3. If you look at overall death rates and rates of MI and stroke, statins probably do not benefit men who are at low risk for developing coronary artery disease, even if their cholesterol numbers are high. Risk factors include smoking, hypertension, diabetes and age.
4. Whether statins are beneficial for men who are at high risk for developing coronary artery disease is controversial.
Fortunately for me, this is not often an issue in jails. If a patient comes into jail on a statin, I will usually continue it. Inmates rarely stay long enough for me to begin discussions of cholesterol numbers. But this is a big deal in prisons. Should a 50 year old inmate at low risk of developing coronary artery disease be started on a statin just because his total cholesterol is, say, 220? I would say no–he needs to be counselled on healthy lifestyle practices. But I would like to hear your opinions!