Managing Cholesterol Medication With Treasure Valley Family Medicine

The American College of Cardiology (ACC) and the American Heart Association (AHA) regularly update their recommendations on who should be treated with cholesterol lowering medications; the most frequently used class is the statin group which includes simvastatin (Zocor), atorvastatin (Lipitor), and rosuvastatin (Crestor) among others. In this article we’ll discuss the current recommendations as of 2019 and when it might be reasonable to stop statin therapy.

How do statin drugs reduce heart attack and stroke risk? In summary, 1) they reduce the bad (LDL) cholesterol which promotes blockages in arteries, 2) they possibly exhibit an anti-inflammatory effect, and 3) they stabilize existing artery blockages and prevent them from rupturing like a volcano – which causes immediate cell death (pleiotropic effects). The goal for most patients is to reduce LDL levels by 30-50%. In higher risk cases, we aim for an LDL less than 70 mg/dL; this includes those with diabetes or existing heart disease.

Healthcare providers use a probability calculation referred to as the “10-year risk of atherosclerotic cardiovascular disease (ASCVD)” to determine who would benefit most from therapy. This calculation utilizes data from population-based and clinical trial outcomes to predict the likelihood that a patient suffers a heart attack or stroke within the next 10 years. The calculation also includes a patient’s own cholesterol and blood pressure numbers as well as the presence of additional risk factors such as age, gender, smoking and diabetes history. A low 10-year risk is less than 5% while a very high risk is over 20%.

Experts agree on a few things; for example, the following groups of people should take statin medications:

The catch is that the above guidelines typically apply only to people younger than 75 years of age. Until now, there simply hasn’t been enough data to suggest benefit for those trying to prevent heart disease in their later years. The general recent consensus has been that patients and providers discuss the individual risks and benefits and should consider stopping statins after age 75.

While statin side effects are generally mild, they do become more significant as a person ages. Older patients are also more likely to be adversely affected by cost and potential drug interactions.

There is also mixed evidence as to the effect of statins on cognitive ability later in life. Some research suggests there is a short-term, reversible, decrease in memory immediately after starting a statin–something older patients might be very concerned about. There is also evidence, however, that statin use lowers the overall risk of dementia – showing the conundrum of medication use in older patients.

A recent French study (July 2019) suggests that there is still benefit to statin therapy beyond age 75. This observational study, which is unable to determine causation, showed that those over age 75 who stopped their statins were 1.46x more likely to suffer a heart attack and 1.26x more likely to have a stroke. In real terms, this means that we might expect an extra 2.5 cardiovascular events per 100 people within the first four years of stopping statins at the age of 75 year compared to those who continue taking them. A 2019 meta-analysis in the journal Lancet also concluded that limited evidence supports continuing statin meds in those past age 75 yo; greater benefit of statin use was seen in those younger than 75 yo.

At Treasure Valley Family Medicine, we believe in having these important discussions with patients and their loved ones. We go as far as doubling, and even tripling, the average appointment time of other practices to ensure that this happens.

Fighting Asthma with Treasure Valley Family Medicine

According to the American Academy of Asthma, Allergy and Immunology, just under 10% of Americans suffer from asthma. Asthma is a respiratory illness characterized by chronic swelling and excess mucus production in the airways. While we don’t know the exact cause of asthma, researchers believe it’s a combination of genetics and environmental triggers that creates the lung inflammation, which causes wheezing, coughing, chest tightness and shortness of breath.

A recent report from the Global Initiative for Asthma (GINA) has recommended a massive change in the way we treat this troublesome disease. For the last several decades, healthcare providers have been treating mild or intermittent asthma attacks with the inhaled medication albuterol (Ventolin, ProAir). It provides rapid relief and has thus become known as the “rescue inhaler”. Albuterol’s biggest drawback, however, is that its effects are short-lived, lasting approximately 4 hours. It also does NOT reduce inflammation: the main pathology in asthma. This has led some patients to suffer more frequent attacks and hospitalization when they only use albuterol without any anti-inflammation medicine.

More persistent or severe symptoms have been treated with daily preventive inhaled steroids. These are powerful anti-inflammatories but do not come without consequences. Long-term use in children has been associated with a slight reduction in bone growth, for example. They also require patients to rinse their mouth after use to prevent oral thrush. The most severe cases of asthma are treated with short courses of oral steroids.

Upon reviewing two new clinical studies, GINA no longer recommends the typical albuterol rescue inhaler for those with new or mild asthma. Both of the studies in question showed that patients treated with the albuterol inhaler alone had more exacerbations than those treated with “as needed” use of a combination inhaler with a steroid and a longer-acting medication called formoterol. Like the albuterol inhaler, this particular combination has rapid onset of action but also a longer effect to go with its’ anti-inflammation properties. Examples of this combination include Dulera™ and Symbicort™. This new method also allows for less steroid use overall in both adults and children!

Your primary care providers are a great place to start for diagnosis and management of asthma. We conduct in-office spirometry exams to measure how well the lungs work and to objectively diagnose things like asthma and COPD. We work with patients individually to develop a treatment and action plan.

If you or a loved one suffers from asthma or other respiratory troubles, make an appointment with a Treasure Valley Family Medicine provider today!