2013 Revised Guidelines for Cholesterol (specifically the use of statins)

2013 revised guidelines for Cholesterol 

(specifically the use of statins)

 

In November/ December 2013 the American Heart Association (AHA) and the American College of Cardiology (ACC) released new guidelines for the prevention and post treatment of strokes and heart disease. These new guidelines are far reaching and change the landscape “to avoid heart disease and stroke by prescribing drugs called statins for some, treating obesity as a disease, and other resources to stay healthy” (American Heart Association, 2013). The new guidelines are a radical shift in policy reflecting additional research and a better of understanding of the issues involved (Williams, 2014). The new standards of treatment are offer a more patient centered approach than previous guidelines issued by the AHA and ACA (Williams, 2014).

 

The guidelines focus on four major areas and actually changes the basic discussion of the use of statins for some diabetic patients, while at the same time giving doctors more leeway in ethically prescribing statins for others (American Heart Association, 2013; Williams, 2014). Here is a summary of the guidelines:
The new approach is to assess the overall basic health of the patient being prescribed statins. This includes four general areas:

 

“Cholesterol, Lifestyle, Obesity, and Risk Assessment”

(American Heart Association, 2013).
The new guidelines recommend statin use for people who fall under the following criteria:

 

1. “People without cardiovascular disease who are 40 to 75 years old and have a 7.5 percent or higher risk for having a heart attack or stroke within 10 years.

2. People with a history of a cardiovascular event (heart attack, stroke, stable or unstable angina, peripheral artery disease, transient ischemic attack, or coronary or other arterial revascularization).

3. People 21 and older who have a very high level of bad cholesterol (190 mg/dL or higher).

4. People with Type 1 or Type 2 diabetes who are 40 to 75 years old”

("Doctor discussion is key for cholesterol treatment," 2014)

 

This is a major change from guidelines with hard and fixed rules about the use of statins. According to Craig Williams “Medications offer tremendous benefits, but those benefits have limits” (2014). Superficially using a more flexible as opposed to a fixed limit setting may have a direct benefit in how medications are prescribed and to who they are prescribed (Williams, 2014).

 

For instance under the older guidelines it was always assumed that lower bad cholesterol (LDL) and higher good cholesterol (HDL) was better (Williams, 2014). But if the bad cholesterol is well controlled there may not be much benefit to raising good cholesterol simply for the sake of raising it (Williams, 2014).

 

This statement hit me very hard, since my LDL (up until February at least) had always been in an exceptional range but my HDL was always a tick below standard. The Cardiologist had threatened several times to increase my statin load in order to raise the HDL. I was not opposed necessarily, but come on doctor HDL is 39 and you want 40 and you want to raise the amount of statin dosage to achieve one more point? I mean maybe we are as close as we need to be. It had been an ongoing debate as my HDL would fluctuate between 35 and 39. While the LDL stayed in exceptional range.

 

I believe such discussions will continue but on a different field. Clearly under the new guidelines individual Doctors are to be the arbiters of how they want their patents cholesterol readings to balance out. But no longer should the number be the sole and only determinate.

 

The AHA and ACA estimate that roughly 33 million Americans currently take statins. Some sources suggest that as many as 100 million Americans (or roughly 1/3) might benefit from using statins. A number of these additions are obese people who do not currently take them, most type 2’s, ages 40 to 75 and almost all former heart and stroke patients who do not currently take statins. Notice the group not included, type 1 and 2’s less than 45 years of age. This group has routinely been placed on statins as a preventative measure. Absent other risk factors, these patients may not directly benefit from stain therapy. Of course no one should remove themselves from statin therapy except under the advice of their personal physician. Statin therapy withdraw can have detrimental side effects unless it is done properly. Remember Statins are big drugs. Yes most are now generic and cost very little but do not be lulled into believing that you can simply stop taking the medication. As I told my Cardiologist as she was fretting over my most recent numbers, (something I am fretting over as well) I am not comfortable reducing the drug, but unless there is a reason to increase it, I am not comfortable raising it either.

 

I have not seen her since my largest upshot ever in LDL. I will see her in August and we will renew the discussion, get new testing and see if the uptick is the drug reaction (the offending drug now removed) that I believe it is. If it is, we will come to a detente’ over more statin use. If not, well her point will be well taken. While I hate taking pills if the February result was not a mere blip on the radar screen, well I can expect more and more powerful prescriptions will be written. Frankly if it this large, I will need them.

 

References

 

American Heart Association. (2013). Understanding the New Prevention Guidelines. Retrieved March 25, 2014, from
http://www.heart.org/HEARTORG/Conditions/Understanding-the-New-Prev...

Doctor discussion is key for cholesterol treatment. (2014). Explanation of the new heart disease and stroke prevention guidelines, (3 of 5)

Retrieved March 25, 2014, from http://blog.heart.org/doctor-discussion-is-key-for-cholesterol-trea...

Williams, Craig. Patients are the Guidelines. Diabetes Forecast, April 2014.

 

 

-30-

rick

Views: 133

Tags: Blog, Diabetes, Statins, TUDiabetes

Comment by Brian (bsc) on March 25, 2014 at 7:41am

I refuse statins, in fact I usually ask my doctor to Not test cholesterol. Notice how the new guidelines dropped all the concern over LDL. Why? Because the evidence has become so abundantly clear that LDL is not a risk. And the idea that your doctor would suggest that statins raise HDL. They never raised HDL, they lower HDL. Take Niacin to raise HDL. Or even better, eat more saturated fat.

And what makes me totally spitting mad. Putting out a recommendation that all diabetics be on statins. There is no evidence for that. That is just irresponsible. We might as well just give up on the ACA and AHA and just have the pharmaceutical companies develop the guidelines.

Comment by rick the "Blogabetic" on March 25, 2014 at 9:16am

Brian I knwo there of strong feelings among many members over statin use. i personally do not share those concerns but I do understand the concern. My dad at age 81 was placed on a statin and it nearly ruined his life, because he oculd no longer sleep. Under these guidelines he would have been a marginal call at best for the use of statins. In his case the Dr. removed the statin but the issues never really resolved prior top his death. No I do not think statins played any role in his death, but it made it more difficult for him to live those final couple of years. Something that was unnecessary in my opinion. So yes I do understand the concern.

Comment by Brian (bsc) on March 25, 2014 at 10:15am

I'm sorry about your dad.

Comment by Kathy on March 25, 2014 at 1:54pm

Yeah, I know the confusion is significant. I have taken simvistatin for 10 years. My primary takes it, my nephrologist takes it, and my cardiologist takes it. I was just told that my lipid levels were "splendid", so I guess I'm gonna continue. I need to have every favorable assistance that's available.

Comment by David (dns) on March 25, 2014 at 3:15pm

I second Brian. I won't have anything to do with statins and I dumped the one I was on without asking permission first. Since going low carb, I have lipids that would do credit to a healthy 21 year old. Statins are among the most side-effect-laden drugs out there, and none of the side effects are good. I would need an overwhelmingly compelling reason (backed by overwhelmingly compelling evidence) to consider going near one.

BTW - did you notice that the requirements stop at age 75? I guess at that point you can do whatever you want, regardless of health status.

[censored]

Comment by rick the "Blogabetic" on March 25, 2014 at 6:01pm

I did notice David. I wonder (I have no idea) if the thinking is that at age 75 if you have one of the risk factors you have gone long enough that it may not do much to lower the cholesterol. Or I wonder if like my Dad, the placement of a person on statins has other issues that cause more problems then it solves.

I do know that my dad was miserable and he said he had significant non voluntary leg movements at night. As I said Dad went off but it took almost a full year and while I do not in anyway believe it contributed to his death (he had liver cancer) I have no doubt he was in a difficult spot the last three years of his life.

Comment by Terry on March 26, 2014 at 12:15pm

I find myself squarely in the Brian and David camp! I took myself off of statins last November. I was on them for about 10 years. I didn't ask my doctor's permission. I knew she took the conventional party line on statin use for diabetics.

Fully half of the "expert panel" in the recent study had material conflicts of interest. They received speaking fees from big Pharma as well as funding for their studies that led to career enhancing publication in the medical journals. Do you really think that these fees and funding had no effect on the published result?

The medical literature rarely uses the term NNT or "number needed to treat." This is the number of people that need to take a medication in order for one of them to avoid the problem outcome, like a heart attach or stroke. The NNT for statins is something like 200. So 200 people need to take statins for something like three years in order for one of them to avoid a bad outcome. Yet a high percentage of that 200 will come down with some side effects, some of which are not reversible.

All the statin trials filter out people that exhibit known side effects before the actual trial period starts. If these people were counted, then the statin side effects would be a much greater percentage.

Why is it that of all people who have their first heart attack, about half of them have perfect cholesterol numbers? Just check out the comments about Tim Russert, who died at 58 with great cholesterol numbers. Conversely, what about all the people with very high cholesterol numbers that don't have heart disease?

I have high total cholesterol, high LDL, but also high HDL and low triglycerides. When I had a more expensive cholesterol test done that directly measured my LDL, I discovered that 80% of my LDL was the large fluffy benign type.

I spent hours and hours reading all the literature that I could access. What I gleaned from all that time spent was many researchers suspect that inflammation as a contributor to heart disease. My last CRP test (a blood marker for inflammation) came in at 0.3 with an upper limit of 1.0. (sorry, I don't remember the units.)

I recently became aware of a cholesterol study done on a geriatric population. They divided the study group into thirds base on their cholesterol numbers. The group with the highest mortality from all causes? The ones in the lowest third! The highest third cohort had the lowest all cause mortality.

I told my doctor that I will not take statins going forward and while she didn't agree with me, she accepted my decision and said that she will no longer measure my cholesterol. I was glad to hear that.

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