Worries about 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 mycardiologist if thesenumbers were too low, and he said they were great but if I was that concerned I could cutmy atorvastatin to 20mg a day. Are these too low? — D.R.

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 seemed to show behavioral changes. However, less than 1% of trial subjects had that complication in two trials. There has been a concern that colon cancer might be more likely, but that has not been seen. Muscle aches 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 knowabout.