Reader worries about his very low cholesterol level

DEAR DR. ROACH: I am a 67-year-old male who had a major heart attack 19 years ago. I am very active. Prior to the pandemic I was going to the gym five days a week and then came home and spent a few hours doing yardwork and gardening. I still spend two to four hours a day in my yard. This past week I had lab work done with a full lipid panel. I take 40 mg of atorvastatin daily and inject 140 mg/ml of Repatha every two weeks. My total cholesterol was 79 and my LDL was 9. I asked my cardiologist if these numbers were too low, and he said they were great but if I was that concerned I could cut my atorvastatin to 20 mg a day. Are these too low? Are there any health risks from having too low a level of cholesterol? -- D.R.

ANSWER: Cholesterol has normal functions in the body, and there have been theoretical concerns about having such a low cholesterol. Although medicines like evolocumab (Repatha) are relatively new, there are accumulating data that suggest the concerns are not as great as feared.

Because Repatha and alirocumab (Praluent) are given by injection, they can cause reactions at the injection site, such as soreness and bruising, but otherwise the side effects are roughly the same as in placebo.

Some early trials of different cholesterol lowering medications (before statins) seemed to show behavioral changes, researchers were concerned there might be effects on the brain. However, less than 1% of trial subjects had that complication in two trials, and none did in another large trial. There has been a concern that colon cancer might be more likely, but that has not been seen. Muscle aches, often seen with statins, have not been a problem with the PCSK9 inhibitors.

For a person like you with a history of a large heart attack, the benefits of such a low LDL do seem to outweigh the harms, at least as we understand them now. Studies are ongoing to see whether there may be long-term effects we don’t yet know about.

DEAR DR. ROACH: Is it possible for someone in their 80s to develop lactose intolerance or a gluten sensitivity? -- T.D.

ANSWER: Lactose intolerance most commonly develops in childhood or adolescence, but it may occur at any age. There are diagnostic tests, such as the hydrogen breath test, that can make the diagnosis with high certainty.

Celiac disease -- a sensitivity to the protein in gluten -- may also be diagnosed at any age, with about a third of people diagnosed over the age of 65. It is likely that many people diagnosed at an older age have had gluten sensitivity for a long time before diagnosis, as the range of severity of the symptoms is very wide. However, it’s clear that some people will develop sensitivity at older ages. Like lactose intolerance, celiac disease can be diagnosed with certainty, using a combination of blood antibody testing and small bowel biopsy.

Symptoms of these conditions can be similar, especially diarrhea. I recommend getting a diagnosis. Not only can the proper diet be recommended, but there are also other possibilities that should be evaluated if celiac and lactose intolerance are both ruled out.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.