San Antonio Express-News (Sunday)
Does high ‘good cholesterol’ render a statin unnecessary?
Q: My doctor is insisting I take cholesterol medicine after I’ve refused to for years. I am 66 years old, and my total cholesterol is 301 (triglycerides 76, HDL 83 and LDL 206). He has prescribed rosuvastatin, 20 mg a day. I feel with my triglycerides and my HDL being good levels that perhaps the dose may be a little excessive. I know that I am not a doctor, but I would like a second opinion on my doctor’s prescription.
A: You are right that your high HDL cholesterol reduces the risk, but most guidelines do recommend statin treatment based on your very high LDL cholesterol.
In studies among people with an LDL as high as yours, those studied were less likely to have a heart attack or stroke when taking the medicine. By making some assumptions and with the use of a risk calculator, I can estimate your risk of a heart attack or stroke in the next 10 years to be in the range of 6 percent to 7 percent. However, your blood pressure, smoking history and other medical information would be necessary for a more complete estimate, and few calculators consider family history and other nontraditional risk factors.
Taking a statin drug like rosuvastatin (20 mg is a hefty dose — not the highest, but it would still be considered high-intensity) would be expected to reduce your relative risk by perhaps 20 percent, meaning an absolute risk drop of about 1.5 percent. I am not a physician who “insists” my patients take a certain prescription. I’d rather try to provide enough information to let my patient make an informed decision, although when I think they make an unwise choice, I try to convince them.
Sometimes, a compromise is warranted. If 20 mg makes you uncomfortable, why not take 10 mg? It will still provide a significant benefit in protecting your heart and brain. My experience is that when a patient is comfortable with a treatment plan, they are more likely to adhere to it and may even be less likely to have a side effect of the medication.
Q: Should I get the COVID-19 vaccine? I’m an 82-year-old female who had Bell’s palsy in 1989 and later fibromyalgia for many years. I stopped getting flu shots, as I think that’s why I got Bell’s palsy. Is it advisable for me to get vaccine?
A: Bell’s palsy is a paralysis of the facial nerve on one side.
The majority of these are thought to come from a viral infection, especially herpes simplex virus 1, the kind that causes cold sores. I do not recommend you stop flu shots.
I certainly advise a COVID-19 vaccine for a person like you, as I do not think there is an increased risk of Bell’s palsy, fibromyalgia or other complication based on the millions of people who have now gotten the vaccine.
Most vaccine side effects, if they occur, will happen immediately or very shortly after vaccination, and almost none after six weeks or so. Balanced against a possible but certainly small risk is an immense benefit of protection against COVID-19,
which has killed millions of people worldwide. In addition to the great number who have died, there are many, many more who have long-term complications. The benefits dramatically outweigh the risks.
Q: I have had more than 50 vaccinations in my life (I’m 78), most of them while I was in the military. I have often wondered how the vaccine spreads throughout the body, as the shots are almost always given in the upper arm. I would welcome your explanation of what exactly takes place. Pardon my ignorance.
A: Recognizing what you don’t know is a sign of wisdom, not weakness.
Vaccination is a way of establishing immunity to an infection
without getting the actual disease. The term “vaccine” itself is from the Latin word for
“cow,” recalling how exposure to cowpox caused only a mild skin reaction but provided lifelong protection against the deadly disease smallpox.
A vaccine usually consists of a weakened form of the bacteria or virus causing the disease to be protected against, or a small, noninfectious, purified part of the germ.
After an injection, the inflammatory and immune cells of the body not only destroy the components of the vaccine in your arm, they can “remember” what was injected. This allows the body to be prepared to destroy the actual infection should you get exposed.
Even though the vaccine is destroyed and removed from the body within a few days, the memory cells will usually last your whole life, and many vaccines thus provide a lifetime of protection. Other vaccines require periodic booster shots to maintain high enough immunity to protect you.
The first two COVID-19 vaccines use a new technique: mRNA “tells” the muscle cells in the arm to make a specific protein (the “spike protein”) that the coronavirus uses to enter cells. Once again, the mRNA and the spike protein are destroyed by the natural systems of the body, but not before the body learns how to recognize this critical part of the coronavirus. These vaccines have proven to be very effective at preventing infection, especially serious infection.
Vaccines can be given in other parts of the body. Some are given into the gluteal muscle, especially in children. Some are given orally. But all approved vaccines, even those for emergency use, have been proven to be effective.
Q: I have osteoporosis caused by heartburn medication. So now what type of osteoporosis medicine can I take?
A: Proton pump inhibitors such as omeprazole (Prilosec) can interfere with the body’s ability to absorb calcium. There is a small increase in osteoporosis among long-term users of PPIs, although the evidence for an increase in fractures is less convincing. Still, I recommend increasing dietary calcium in women and men on long-term proton pump inhibitors — and thinking twice before using proton pump inhibitors long term to begin with, unless they are absolutely needed.
If a person continues to have osteoporosis despite adequate calcium intake, and if the PPI has been stopped or can’t be, then it is reasonable to consider medication treatment for the osteoporosis. It may be that you were going to develop osteoporosis even without being on a PPI.
First-line treatment for osteoporosis is usually a bisphosphonate, such as alendronate (Fosamax) or risendronate (Actonel), since there is strong evidence that they are effective at preventing fractures. People taking these medications should be re-evaluated after three to five years of treatment. Treatment may often be stopped or paused then, as there is a risk of atypical fractures of the hip after that time.
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.