Reader worries about his very low cholesterol level

DEAR DR. ROACH » I am a 67-yearold 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.

DEAR READER » 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?

— T.D.

DEAR READER » 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.