Cholesterol Treatment

Hi, thank you for coming back for the latest edition of Beyond Primary Care’s blog- Cholesterol Treatment. In Beyond Primary Care blogs we highlight healthcare news, advice for medical conditions, and how membership for care works! Beyond Primary Care is an insurance free, membership based family medicine clinic. Beyond Primary Care is the highest rated Direct Primary Care clinic serving patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne counties giving families and employers peace of mind about healthcare costs by providing affordable and accessible primary care services.

In this blog post, we wanted to expand on our past blog article about what is cholesterol and it’s diagnosis to further educate our patients and any prospective patients on cholesterol treatment.

Cholesterol Treatment

Cholesterol, originally named ‘cholesterine’ (solid bile in Greek: chole for bile and stereos for solid) was first isolated from gallstones in 1784. Since then, it has been a subject of fascination for not only scientists and physicians, but also everyday individuals seeking to lower heart disease risk. 

In fact, the first hint of cholesterol being related to atherosclerosis - which is a thickening or hardening of the arteries caused by a build up of plaque in the inner lining- was in 1910 from Nobel Prize recipients. A genetic influencing relationship between cholesterol and heart disease was made in 1939, when several large families with high blood-cholesterol and premature heart attacks were identified. Starting in the 1950s, the search for a medication to block a part of cholesterol formation began. 

Micrograph of an artery that supplies the heart showing significant atherosclerosis and marked narrowing

Cholesterol Statins

Statins are the work horses of cholesterol management when Merck laboratories received the first US FDA approval for Lovastatin in September of 1987. Statins work by drawing cholesterol out of plaques - thus reducing the size- and also stabilizing the plaques present on the walls of the arteries.

Statins do not cause memory loss or cataracts. Muscle aches tend to be the most common side effect. Though, for some people, eliminating muscle pain can be simply done by increasing vitamin D intake. For others, moving between different statin brands (eg- Lipitor ® vs Crestor ® vs Zocor ®) helps because the medications interact slightly differently in the body. 

The medication helps to lower LDL cholesterol. Statins have been tested in many large-scale clinical trials, some involving 90,000 subjects followed for 5 years. The results demonstrated treatment with stating lowers LDL by 25-35% and reduces the frequency of heart attacks by 25-30%. 

In most people, cholesterol production is peaking in the evening. Thus, most doctors will prescribe cholesterol medications to be taken at night to make sure you have enough mediation in your body when you need it the most. 

At Beyond Primary Care, a 30 day prescription of Lipitor (Atorvastatin) is $0.90.

Cholesterol PCSK9 Inhibitors

The true name, proprotein Converts Subtilisin / Kevin Type 9 inhibitors is a mouthful, will keep to ‘PCSK9.’

The human liver makes this protein, and studies have shown that if you have naturally high levels, you are more likely to have high cholesterol. This drug class lowers LDL “bad” cholesterol by up to 60%, and can be taken on their own or in addition to statins. There are only two FDA approved medications as of the time of this post: alirocumab (Praluent) and evolocumab (Repatha). This are given as shots every 2 - 4 weeks.

Two large cardiovascular trials with nearly 46,000 patients showed a relative reduction of risk by 15% and a 2% absolute risk reduction after two years of treatment. However, one barrier to care with these medications is the cost and high rejection rates of approval for these medications by health insurances. 

Ezetimibe (Zetia)

Zetia is the most common non-statin medication to be used to lower LDL “bad” cholesterol levels. The medication blocks the absorption of cholesterol in the small intestine, causing a reduction in liver stores of LDL. The use of Zetia along with statin medication was initially found to be a potent combination in reducing LDL levels. However, there has been discussion among the medical professionals as to whether Zetia offers additional reduction in cardiovascular risk despite that LDL reduction. A large, 10 year trial did essentially demonstrate that the medication did help and ‘lower is better’ in terms of cardiovascular risk and LDL levels when used in combination with Statins. 

Niacin

Niacin (Vitamin B3) is considered to be the most powerful medication from the viewpoint of increasing HDL “good” cholesterol. Having high HDL levels means a lowered risk for cardiovascular event. Niacin also results in a small but measurable reduction in LDL cholesterol and triglycerides. Escalating doses of Niacin between 500 mg to 3,000 mg are used nightly. 

Niacin does have undesirable side effects that may occur, such as flushing, pruritus (itching skin), headaches, and belly discomfort. Niacin is water soluble, meaning excess amounts the body does not need are excreted in the urine. Unfortunately with Niacin, studies have shown disappointing results indicating there is no additional benefit achieved by adding Niacin to an existing cholesterol reduction plan with statins. 

Red Yeast Rice

Red yeast rice has been used for centuries in Chinese medicine to lower cholesterol, improve blood circulation, and improve digestion. Red yeast rice contains monacolins, a chemical that in a similar fashion inhibits HMG-CoA activity, resulting in a reduction of cholesterol. Studies have shown that individuals enrolled in a lifestyle change program and received 1,800 mg of red yeast rice showed lower LDL levels than control groups. No notable changes occurred in HDL or triglyceride levels. If you are going to use red yeast rice supplements, most major supplement brands on the market generally recommend taking between 1,200–2,400 milligrams daily, divided into two or three doses

Just like Niacin, safety concerns exist because of variations in concentrations of monacolin K- which often varies greatly manufacturer to manufacturer. If the process of controlling this monacolin K is flawed, a chemical constituent called Citrinin can form, which is linked to kidney damage. 

If you choose to use red yeast rice supplements, try to select a high-quality one. Please ensure the supplements come from a certified Good Manufacturing Practices (cGMP) facility, which meets US Food and Drug Administration criteria.

Fish Oils

According to a scientific advisory published by the journal Circulation, 2-4 grams a day of prescription Omega-3 can lower triglyceride levels by 20%-30% in most people. Omega-3 medications comes in two forms. One form combines two types of fatty acids, EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid). It is important to take supplements with both EPA and DHA to maintain a balance between the two. Omega-3 supplements are effective regardless of whether people are on statin therapy. It is important to realize that the average Omega-3 capsule contains only 1,000 mg, meaning many people should take at least 2-4 capsules a day.

What to do?

At Beyond Primary Care, we stock medications and supplements for our patients.

Consider making an appointment at Beyond Primary Care. Beyond Primary Care is a Direct Primary Care clinic located in Ann Arbor, Michigan and cares for patients all throughout Washtenaw County, Wayne County, and Livingston County.

Thank you for reading
To make an appointment with Dr. Jeff O’Boyle please see our scheduling link.