December 22, 2011       Issue #4

Dear Friends,

In this issue of the Newsletter, I will discuss a very common medical problem: cholesterol. I think most people are aware that high cholesterol

is strongly associated with arterial blockage, thereby increasing the risk of heart attacks and strokes (and other arterial conditions). If you have high cholesterol and you also smoke or have diabetes or hypertension, your risk is even higher. What I’d like to focus on in this Newsletter is to give you some practical information about interpreting your cholesterol results and the different forms of treatment for lowering cholesterol.

There are several types of cholesterol. LDL and Triglycerides are “bad” cholesterols. HDL is the “good” cholesterol. The total cholesterol is a measure of all the different types. Just knowing your total cholesterol does not give us enough information to determine whether your cholesterol pattern is bad or not. (i.e. your HDL cholesterol could be very high, making your total cholesterol be high, but this is not a bad pattern by any means). There are other forms of cholesterol, but these are the main ones that we currently pay attention to.

For LDL, we try to get it less than 100. If you have diabetes or heart disease or are at high risk for heart disease, we try to get the LDL less than 70 if possible. Almost all cholesterol meds will lower LDL to some extent, but the “Statins” are the most powerful in lowering LDL. Common examples in this family include: Crestor, Lipitor, Zocor (Simvastatin), Pravachol (Pravastatin), Lescol, and Livalo. “Statins” work by inhibiting the production of cholesterol in your liver.

The main problem with the “Statin” family is that they can cause muscle aches/cramps. Some patients are very susceptible to this side effect. If you experience a side effect with a statin, sometimes switching to another member of the statin family is effective, sometimes not. If we are forced to abandon the “Statin” family, I usually use Zetia. Zetia works by binding cholesterol in your diet and not allowing it to be absorbed. It doesn’t get absorbed into your bloodstream, therefore it really doesn’t cause muscle cramps commonly. If Zetia is not tolerated or is not strong enough, I will usually use one of the “Fibrates” or Niacin (see below).

For Triglycerides, we try to get it less than 150. Triglycerides can become extremely high in rare cases. I’ve seen patients with Triglycerides in the 7,000’s or higher. Triglycerides tend to be strongly linked to diabetes. Sometimes, the triglycerides can be significantly improved by simply getting the sugar under better control. The main family of medications that help triglycerides are the “Fibrate” family. Examples include: Lopid (gemfibrozil), Tricor (Fenofibrate), and Trilipix. Lopid is the oldest and therefor the least expensive. It’s also the one that interacts with other meds the worst. I prefer to use Tricor or Trilipix to minimize the risk of drug-to-drug interactions if the cost isn’t prohibitive for the patient. Fish oil or Flax Seed Oil in high dosages also help lower the triglycerides. You probably would have to take 9 tablets of the typical Over-The-Counter fish oil supplements to really get any benefit. There is a prescription medication called Lovaza that gives a much higher concentration of the essential fish oils and it is a viable alternative to the Fibrates. If Lovaza or the Fibrate family aren’t tolerated or aren’t effective, I usually use Niacin or Statins. Niacin does a nice job of lowering Triglycerides, but its use is limited by side effects (see below). The Statins are not nearly as effective in lowering Triglycerides as they are for LDL, but can help sometimes.

For HDL, we want it to be high (since it’s the good cholesterol). HDL travels through our bloodstream and eats up the blockage caused by LDL and Triglycerides. Regular aerobic exercise helps raise the HDL. Our goal is to try to get it above 40 and preferably above 45. If I see a patient with an HDL in the 20’s, I would consider adding a medication to try to raise the HDL. In my opinion, the best medication available is Niaspan (Niacin) for raising HDL. Niacin is a vitamin that we all eat in our foods every day, but in higher dosages, it can stimulate our livers to make HDL. It also lowers triglycerides pretty well and lowers LDL to a lesser extent. It would probably be the first line treatment for all types of cholesterol problems if not for the side effect profile. Niacin tends to cause skin flushing, hot flashes and palpitations that are very uncomfortable and occur with almost every patient that tries it. Niaspan (the brand name formulation of Niacin) is specially formulated and coated to try to minimize these side effects, but it still happens quite often. If you are taking Niaspan and have flushing or other nuisance side effects, you can try taking it with an aspirin or with a low-fat snack (like applesauce).

There are many people who have a combination of cholesterol abnormalities. In fact, a diabetic might commonly have high LDL, high Triglycerides and low HDL: the worst of all worlds. It is commonplace for me to recommend a combination of medications. That’s why I don’t like Lopid (gemfibrozil): it has a higher risk of dangerous interactions if I have to mix it with a Statin (especially Zocor [simvastatin]).

I would be remiss if I didn’t also mention that the good cholesterol can be increased and the bad cholesterol can be lowered naturally without medications by following a low-fat, low-cholesterol diet and regular aerobic exercise. For mild elevations in cholesterol, lifestyle modification is certainly the preferred method.

Patient Portal update:

So far, I’m getting very positive feedback on the patient portal. I encourage all patients who are interested to sign up for this service. Just to review, the Portal allows you unprecedented access to your chart 24 hours a day. I try to post all your x-rays, blood tests, and other important tests (like EKGs) on the Portal. It allows you to read my comments at a time that is convenient to you and also allows you access at a later date. (i.e. you develop chest pain 6 months from now and go to the ER at 3AM. You’d be able to pull up your EKG and your cholesterol from your chart for the ER doctor to review. You can also pull up your medicine list with dosages, your past surgical history, your immunization history, etc). It also allows you to request appointments and request medication refills 24 hours a day.

A few minor tips: If you request a medication refill on the portal, please check to see if my name is listed under “provider”. This is a quirk of the program. If my name isn’t listed under that particular medicine, when you request the medicine, the computer doesn’t know who to give the message to. (It should, since I’m the only doctor, but it doesn’t). As soon as I refill the medicine for you officially, it will link it to my name from that point on. So the first time you need a refill, you may need to ask me in the office or call us. But as soon as I write the first prescription for that medicine in my new chart here at the new office, it will be listed under my name after that. Sorry about this glitch. It will become less and less an issue as we use the new system more and more over time.

Also, if you choose to sign up for the Portal, you will receive an email the next business day with your login information. It isn’t immediate. Many of our emails are getting snagged by patients’ SPAM folders. You might put “parisfamilyphysicians.com” as a trusted entity on your email program. If you do somehow delete that email from your SPAM folder, don’t panic. Just call us and we can assign you a new username and password.

If you’re still undecided about the Patient Portal, please try it out for free. Log on to ParisFamilyPhysicians.com and click on “click here to enter the Patient Portal”. You’re brought to the login screen. Use “bbunny” as username and “bbunny” as password and you can log into “Bugs Bunny’s” chart to see how the Portal looks on a sample patient.

Please give us your feedback. We appreciate your trust in us for your health care needs. I hope you have a wonderful Christmas and a Happy New Year!

                                                Sincerely,

                                                Jeffrey Green, MD