Other Problems with Controlling Cholesterol

Other Problems with Controlling Cholesterol

The line-up of genes each of us has might be thought of like the line-up of a baseball team. Each individual player has specific strengths and weaknesses. For the most part, the players are predictable in what they will do over a period of time.

The genes we inherit from our parents have specific strengths and weaknesses. We can often predict problems a person will have with his or her body, depending on the line-up of these genes. Unfortunately, you may get a gene that is going to cause you a lot of problems-such as not having enough LDL receptors to manage this harmful cholesterol. Someone with this genetic pattern has familial hypercholesterolemia.

As we’ve talked about, when we eat too much saturated fat and trans-fatty acids, our bodies make cholesterol. People with normal LDL receptors can handle some of this lousy cholesterol, but may have a problem if they continue to eat large amounts of saturated fat, as most people do in our culture. We are concerned about you whether or not you have familial defects in your genes that prevent your body from controlling cholesterol or triglycerides. That’s why we think families should go on our bad-fat budget program together— not just people who are in an especially high-risk group.

A few people do inherit genes from their parents that make controlling cholesterol and triglycerides extremely difficult. Even though they limit the bad fat and cholesterol they eat, exercise regularly and don’t smoke, they may not be able to get their cholesterol or triglycerides into a safe range. They may have a lipid disorder (i.e., a cholesterol or triglyceride problem where the total cholesterol, LDL cholesterol or triglyceride is too high for their HDL cholesterol).

What can someone like this do? We can’t choose new parents. Even though some breakthroughs are occurring in genetic engineering, for now we are stuck with the genes they gave us. It’s mind-boggling to think about the millions of possible combinations of genetic traits that each of us has after chromosomes have paired up from our own parents, each of their parents, and each of their parents and so on. Some inherited traits determine whether we have brown eyes, blue, hazel or some other color. Some traits are dominant, others are recessive. Some traits give us big advantages in strength or other various physical characteristics. Still others give major weaknesses or defects, such as certain kinds of blindness, deafness, diabetes or muscular dystrophy. Others get genes that make it difficult to control cholesterol and triglycerides.

The good news is that if we happened to get genes that cause diabetes, we can do something about it. By regulating what is eaten, exercising and taking insulin and/or medications to help control the high blood sugar, someone with diabetes can usually attain excellent control. So most people with diabetes can live happy lives without the worry of blindness, premature death and other serious problems that uncontrolled diabetes often cause.

What if you picked out some really great parents, who happened to pass on a genetic trait of not enough LDL receptors or a disorder that makes your triglycerides go up like crazy when you eat a little fat? Just as diabetes can be controlled with insulin, a person who can’t process fat can be helped with medications. Which medication is chosen depends on the particular problem a person has in handling fatty acids.

Almost everyone with a cholesterol over 300 or triglycerides over 400 has an inherited tendency to over-manufacture these fats or an inability to control their production. Others who don’t have levels nearly this high also may have a dangerous familial problem. Low-fat diets alone are not enough to reduce and control harmful cholesterol and triglyceride levels in these people. They almost always need medications.

Even so, every plan to control high cholesterol and triglycerides levels must be built on a solid foundation of an ongoing low-bad-fat diet.

Exercise is also extremely important.

It is absolutely necessary not to smoke.

Close monitoring of elevated total cholesterol, LDL, a high cholesterol/HDL ratio, low HDL levels and/or triglycerides by an interested and informed physician is important.

Medications to Control Cholesterol and Triglycerides

Let’s talk about some medications used to control abnormal levels of cholesterol and triglycerides. If you need a medication, you want the best choice and right dosage for you. In general, your doctor should start with the lowest dose of any medicine after a good trial of diet and exercise has failed to bring your numbers to the goal of therapy.

In someone without vascular disease this goal is an LDL cholesterol less than 130 (3.4), a total cholesterol/HDL cholesterol ratio of under 4 and a triglyceride of under 150 (1.7). In someone with known clinical vascular disease the goal is LDL cholesterol under 100 (2.6) and a triglyceride under 100 (1.1). The typical heart-attack victim or bypass patient will usually make it to the goal of therapy with just a pill or two of the current medicines.

Your medical and family history, risk factors, what cholesterol- and triglyceride-controlling medications have or have not done for you up till now all need to be considered. So do your past and present levels of HDL, LDL, triglycerides and cholesterol/HDL ratio. And you want someone to monitor you who has experience with the benefits, limi- tations and side effects of the different medications.

NIACIN

Niacin (nicotinic acid) was one of the first medications used in helping to control high levels of cholesterol. It’s still one of the useful players in the lipid-medication line-up, especially when triglycerides are high and/or HDL is very low. Even though niacin is an over-the-counter medication, never consider taking niacin as a “do-it-yourself” project.

Although niacin should probably be used more often than it is (especially as a second drug), we don’t think anyone should take it unless a physician supervises its use. Why? Niacin has side effects, as does every medication ever created. Once in a while niacin may raise blood-sugar levels and uric acid. These side effects can be an even bigger problem for those with diabetes, gout, gallbladder or liver disease.

As helpful as niacin often is, almost everyone who takes it has a problem with flushing (which feels like burning skin) and hot flashes when the medication is first started and gradually increased.

It may also cause itching. It usually occurs with the first doses and disappears by the third day. It comes back if you skip a day. It will not hurt you and old niacin-takers are used to this sort of thing. An aspirin, even a baby aspirin, taken a half hour before taking the niacin greatly diminishes these flushes.

There is also the matter of choosing between short-acting and sustained-release niacin. The direct-acting niacin or regular niacin is less toxic to the liver than most of the sustained-release niacin. But the sustained-release niacin causes much less flushing, burning or itching. Doses over 2 grams a day usually lead to liver-enzyme changes.

Niacin was the first drug to lead to a lower death rate and it has been used for over 30 years with an excellent safety record. Rare persons may develop jaundice on niacin. Although this is completely reversible, it tells you they cannot take niacin.

GEMFIBROZIL (Lopid®)

Gemfibrozil became a major player in lipid control after it reduced heart attacks 71% in the Helsinki Heart Study. Gemfibrozil is useful when triglycerides are high and the HDL is low. It is often prescribed for patients with high blood-sugar or high uric-acid levels. Because familial cholesterol or triglyceride disorders (especially types III, IV and V) are often difficult to control, it is quite common for persons with these problems to be given a combination of gemfibrozil and niacin or gemfibrozil and atorvastatin.

Side effects are rather uncommon, but can include minor gastrointestinal symptoms such as gas and/or loose stools, especially if relatively high doses are necessary. A few people have rashes or gall-stones (if they cheat on the diet) and even fewer have muscle cramps or inflammation-particularly if used with lovastatin.

Unlike niacin, gemfibrozil does not raise the blood sugar or the uric acid in people with syndrome X. It also blunts the rise of blood sugar and uric acid produced by niacin when it is taken with gemfi-brozil.

STATINS: CERIVASTATIN (Baycol®), ATORVASTATIN (Lipitor®), FLUVASTATIN (Lescol®), PRAVASTATIN (Pravachol®), SIMVASTATIN (Zocor®), LOVASTATIN (Mevacor®)

Statins lower LDL cholesterol the best of any drugs we have and are especially useful when there is high LDL with high triglycerides.

These drugs have added a new dimension to our understanding of the benefits of lowering cholesterol. They have been used in large clinical trials. The Scandinavian Simvastatin Survival Study (called 4S) was done in 4444 men and women living in Scandinavia who had just had a heart attack. Half were given simvastatin (Zocor) and the other half were not. Simvastatin lowered the total death rate 30%, the heart-attack death rate 42% and the bypass and angioplasty rate 37% in just five years. And the non-cardiovascular deaths fell 6%. This study effectively put to rest the cholesterol critics’ claim that lowering cholesterol did not prolong life and that it caused increases in the non-cardiac deaths from suicide accidents and cancer.

Similar data came from studies using pravastatin in the West of Scotland Study. This study included people free of vascular disease, but who were at high risk because of abnormal cholesterol levels. Results: total death rate fell 22%, coronary heart disease rates fell 31%, the non-cardiovascular deaths fell 11% and like the 4S study the angioplasty and bypass surgery rates fell 37%.

Persons taking statins must have regular liver-function tests because these medications may cause liver-function abnormalities.

With a better diet and exercise along with these medicines, people who have particularly bad genes for cholesterol can now expect to live out better-than-average lives. These drugs also allow us to provide people who have had a heart attack with the realistic expectation of reversing their lesions in the next several years.

CHOLESTYRAMINE (Questran®)

These bile-acid-binding resins were the first cholesterol-controlling medications other than niacin. They are available in tablets and packets of resin granules to be dissolved in juice. The most common side effects constipation, increased gas or nausea. They sometimes cause triglycerides to go up instead of down and can interfere with or enhance the effects of other drugs. The bile-acid-binding resins are often the best drugs to use when total cholesterol and LDL levels are very high.

COLESTIPOL (Colestid®)

This resin is supplied in tablets or packets to be dissolved in juice or water. With many of the same benefits and disadvantages of cholestyramine, it maybe tolerated better by some patients.

These two resins, cholestyramine and colestipol, are among the safest drugs. They go in one end and come out the other without being absorbed (blocking the absorption of cholesterol by your intestine and lowering your serum cholesterol). They act like a million little sponges in your intestine, absorbing the cholesterol. Of the cholesterol you excrete from your body, 95% comes out of the liver, down the bile duct and into your intestine. Without these drugs a large proportion is reabsorbed and put back into your blood.

Summary

These medications and others that will be developed provide a way to help lower high levels of damaging LDL cholesterol and triglycerides. They can help to increase the good HDL cholesterol, especially in those people with a familial lipid disorder.

However, one should never rely on these or any other medication to be the magic answer. These medications should never be used— and we mean never-without faithfully limiting the amount of saturated fat and cholesterol that is eaten. A person should never think that once one (or a combination) of these medications is started that he or she can go back to eating more saturated fat-or smoking. It is also important to know that these medications cannot take the place of exercise.

Remember, we’re talking about your life or the life of someone close to you. You have a playbook that can help you win.