Treating lifelong high cholesterol levels is a challenge
DEAR DR. ROACH: I am a 63-year-old female. I have been treated for high cholesterol since I was in my 30s. My cholesterol levels are difficult to control, and as a result I am closely monitored. My meds are adjusted accordingly.
I find this frustrating but am used to it. My weight has ranged from underweight to the upper range of normal, where I now am. When I was 56, I had a heart attack. The blockage was in my left anterior descending artery, and during the catheterization procedure, it was found that I have congenitally narrow blood vessels. Despite two attempts, a stent could not be placed.
My treatment plan, in addition to more meds, was diet and exercise to strengthen my heart.
This was a wake-up call, and I followed my doctor’s advice. I ate healthier and started a daily walking regimen.
A year later I had lost 25 pounds and could walk all day. Subsequent tests show that my heart grew “collateral” vessels and my heart is now normal. As a result, my cardiologist is thrilled.
He has said he wishes I could be a “poster child” to his other patients to prove what diet and exercise can do.
My cardiologist wants his heart attack patients to maintain an LDL level below 70.
Despite diet and 20 mg of Crestor, I cannot get to this number.
Now a new drug, Repatha, is approved. While it has been proven to lower LDL levels significantly, it has not yet been determined whether lowering the LDL that much will actually reduce stroke and heart attack risks.
After much discussion with my cardiologist, I was given the option to go on Repatha.
He admitted he usually doesn’t prescribe “new to the market” drugs but is really encouraged by the data and admits he has many patients on the drug.
I know the drug is administered via an injection and is expensive. I have been screened, and the pharmacy is ready to mail me out the pre-filled syringes.
My insurance will cover it. I am indecisive as to whether I should start this new drug. I am worried about drug interactions. -- B.L.
ANSWER: Evolocumab (Repatha) is a new treatment for high cholesterol, indicated for people at very high risk for heart attack.
This includes people who cannot get their risk down adequately with lifestyle changes and statin drugs, including people unable to tolerate them. Few drug interactions are known (I found only one, with belimumab, which is used for lupus).
Since these drugs are new, there isn’t yet a definitive answer on whether they reduce risk of heart disease -- precisely as you say. However, initial data suggest that they will be of benefit.
The long-term risks of evolocumab are unknown, but short-term risks appear to be low.
The most common is pain at the injection site. Serious adverse events were unlikely. One concern is a small increased risk of confusion.
From what you have told me, you already have done a great deal to reduce your risk.
Using this new medication might further reduce it a small amount, but at an unknown risk of long-term side effects.
However, I think Repatha would be very reasonable for someone at higher risk than you are.
The booklet on cholesterol and its subtypes covers all aspects of cholesterol control.
Readers can obtain a copy by writing: Dr. Roach Book No. 201, 628 Virginia Dr., Orlando, FL 32803. Enclose a check or money order (no cash) for $4.75 U.S./$6 Can. with the recipient’s printed name and address. Please allow four weeks for delivery.