Patient debates ceasing their cholesterol-lowering statin drug

Dear Dr. Roach: I wonder if you could comment on the relative merits of new cholesterol measurements that were recently presented to me. I have been maintaining my total cholesterol level just below 200 (at 170) with 20 mg of pravastatin. At a recent doctor’s visit, I was advised that at my age (74), my cholesterol-lowering statin drug may provide a greater risk than benefit to my health.

Given the makeup of my cholesterol, as measured by the new thinking, I need not be too concerned if my total cholesterol exceeds 200. These measurements include a non-HDL cholesterol level of less than 130 mg/dL (mine is 120 mg/ dL) and a cholesterol ratio less than 3.5 (mine is 3.09). I would appreciate your thoughts. — R.L.

Dear R.L.: The benefits of statin drugs in prevention of heart disease in older adults remain uncertain, as most studies have not looked at many people over the age of 70. This is in contrast to people who already have known heart blockages where the benefits of statin treatment outweigh the harms in nearly everybody, regardless of age or cholesterol levels.

The exact levels of cholesterol where treatment is recommended depends on a great deal of other factors, such as age and sex, family history, and several other medical conditions, so I am not in favor of simplifying this decision with absolute number cutoffs.

It is true that the non-HDL number of 130 does predict risk just as well as a total cholesterol level of 200, but this information alone isn’t enough to make a recommendation for a medicine that most people will take for the rest of their lives.

In your case, your numbers seem to be taken during a time that you are undergoing treatment with a statin. Statins only work when you take them; going off of them will cause your risk of a heart attack to increase, but it will also reduce the risk of a side effect. For my patients, I do not usually recommend stopping a statin based on age unless there is a significant side effect.

As always, the decision belongs to the patient. The doctor has the responsibility of outlining the risks and the benefits so that the patient can make their own informed decision.

Dear Dr. Roach: I have a long history of calcium oxalate kidney and bladder stones. My urologist recently recommended a low-oxalate diet to mitigate stone recurrence. Unfortunately, the diet is so restrictive that I don’t think I can reasonably follow it long-term. Would calcium citrate be a possible therapy? I understand it binds the oxalate anion in the digestive system so that it never gets to the kidneys. — J.S.

Dear J.S.: A low-oxalate diet is a great idea in people with recurrent calcium oxalate stones, the most common type of kidney stones. However, a low-oxalate diet is not a “no oxalate” diet, and you are probably restricting yourself more than you need to.

There are six very high oxalate foods: spinach, rhubarb, rice bran, buckwheat groats, almonds and miso soup — don’t eat those. Be mindful of the other foods on the list, and eat these less often and in small amounts.

Taking calcium by diet reduces stone risk. Experts sometimes prescribe calcium citrate, and you can certainly talk to your urologist or nephrologist about it. But I would first see whether you still have stone issues on a low-oxalate diet.

You are correct in that calcium reacts with oxalate in the gut, forming calcium oxalate, which is not well-absorbed. Further, the citrate in urine inhibits crystal formation.

I recommend the following as a great resource for people with kidney stones on a low-oxalate diet: kidneystones.uchicago.edu/ how-to-eat-a-low-oxalatediet/.