Cholesterol goal change
DEAR DR. ROACH: I am an 85-year-old female. I had a stent placed in my heart artery in 2008, and I have been well since then.
I have been on statins for many years. My present dose is 20 mg of Crestor daily. My recent values are LDL 82, HDL 53 and total cholesterol 154.
The cardiologist tells me that new data shows I should lower my LDL to about 70. I hesitate to do this because the research keeps changing and I tolerate the present dose of Crestor with no side effects. Please tell me what you think.
ANSWER: There was a study a few years ago now (cardiology studies traditionally have witty names; this was called the PROVE-IT study) that compared people with known heart blockages at a high-enough dose of atorvastatin (Lipitor) to get to an LDL of 70 against people treated with pravastatin (Pravachol) with a goal of an LDL of 100. The more-intense atorvastatin group had fewer heart events, such as heart attack, stroke and death, than the pravastatin group.
Whether that was due to atorvastatin being better or to lower LDL being better isn’t clear from the study, but most investigators believe that it is the LDL effect. After two years of evaluation, 26 per cent of the pravastatin group and 22 per cent of the atorvastatin group had had a bad heart event.
In your case, you are already closer to 70 than you are to 100, and you are on a potent agent (Crestor is more similar to Lipitor than it is to Pravachol). Any benefit from pushing your LDL to below 70 with a higher dose is likely to lead to, at best, a modest benefit.
There’s no absolute right answer: You could try it and if you have problems go back to the lower dose, or you could elect to stay where you are. They both are reasonable options. Your opinion matters.
DEAR DR. ROACH: I read in a recent column that you normally recommend against the use of medications in the treatment of osteopenia.
Can you let me know why? I’m 54 and have been diagnosed with osteopenia. My doctor wants me to take Fosamax.
ANSWER: Like all drugs, alendronate (Fosamax) has side effects, and in my opinion the risk of side effects usually outweighs its benefits in people with osteopenia, who have a very small risk for fracture.
With osteopenia (which is a warning, not a diagnosis), I recommend calcium, vitamin D and exercise. When the bone loss is severe (that is, osteoporosis), then the benefits outweigh the risk in most people.
In people with severe osteopenia (approaching osteoporosis), more-frequent checks of the bone density are appropriate to monitor the gain or loss of bone and to begin medications if necessary.
Once a person is on medication for osteoporosis, it’s still important to monitor the bone density.
When it has come up and the risk of fracture has gone down, it may be appropriate for the medication to be stopped, because there are risks with taking medications like alendronate or denosumab (Prolia) for prolonged periods, including atypical femur fractures.
Gallstone after gallbladder surgery puzzles reader
DEAR DR. ROACH: I was diagnosed with Gilbert syndrome after I had a blockage of my common bile duct and became jaundiced. This was three months after I had my gallbladder removed (via an open surgery).
How was it possible for me to develop a stone after the surgery? Was the Gilbert syndrome caused by the blockage?
ANSWER: Let’s start with gallstones, the most likely cause of the blockage. Surgical treatment of gallstones is the most effective treatment, but it is possible, about 10 per ent of the time, to develop a stone after surgery.
This happens sometimes when a stone is retained in the bile duct and is not noticed during surgery. It is more common in laparoscopic surgery than in open surgery.
It also is possible for new stones to form if any remnant of the gallbladder is left. These can be treated with endoscopic removal or with medication to dissolve them.
Gilbert syndrome is caused by a deficiency of an enzyme used to conjugate bilirubin, a component of bile and a breakdown product of red blood cells. It leads to elevated levels of bilirubin in the blood (specifically, a type of bilirubin called unconjugated: the blood tests can distinguish between conjugated and unconjugated). Under times of stress — such as exertion or dehydration — people with Gilbert syndrome can become jaundiced — they exhibit a yellow coloring, which is easiest to see in the sclerae (whites of the eyes) or in the mouth. However, Gilbert syndrome usually does not cause any problems, and does not need treatment.
People with Gilbert syndrome (which runs in families and is very common) are at higher risk of developing gallstones. So, the blockage didn’t cause the Gilbert syndrome: You’ve had it your whole life. The Gilbert syndrome may have put you at risk for the gallstones.
Email ToYourGoodHealth@med.cornell.edu.