The Medical Minute: Lowering cholesterol -- Are diet and drugs enough?

By Robert Zelis and Peter Alagona

Everyone knows that lowering LDL, "bad cholesterol," not only prevents heart attacks, stroke and coronary death, but also helps people live longer. Along with diet, (restricting saturated fats, trans fats and calories) statins (drugs whose generic name ends in "-statin") are the cornerstone for lowering LDL. But for some patients, diet and drugs may not be enough.

With newly recommended lower LDL targets for patients with coronary heart disease or diabetes (LDL goal of less than 100), and an even lower goal in very high risk patients (LDL goal of 70), statins and diet may not be enough. Fortunately, there are three different categories of drugs that work in the intestines to lower LDL cholesterol. When these are combined with statins, most people can reach their goal. These intestinally-active drugs also are useful for the few patients who cannot tolerate a statin. With 20 years of use, statins have been shown to be remarkably safe. However, about 5 percent of individuals are troubled by muscle aches.

Whether patients need to lower their LDL or triglycerides or raise their HDL, or "good cholesterol," Penn State Heart and Vascular Institute (PSHVI) has a specific lipid clinic that is designed to treat high risk lipid patients including those who have had problems reaching their lipid goals. Lipid clinic specialists can find a tolerable drug combination to help most patients, but some patients may be candidates for an even more aggressive therapy -- LDL apheresis.

'Dialysis' for cholesterol

Some people have a genetic problem that prevents them from lowering their LDL enough, even with the best diet and multiple drugs. If the LDL remains above 200 in someone with coronary disease, or above 300 in others, they may be a candidate for LDL apheresis. This procedure is similar to hemodialysis but is much less frequent -- once every two weeks.

Patients undergoing this therapy come to a special room where two intravenous access lines are placed. Blood is continuously withdrawn from one, mixed with a little blood thinner, and the cell-free component of the blood (plasma) is passed through a tube. This contains tiny beads that bind the protein component of the bad cholesterol, allowing it to be removed. Once the plasma has been cleaned of most of the bad cholesterol, it is returned to the patient along with their own red blood cells through the second intravenous line. When the procedure is complete, about three hours later, the LDL has been reduced 73-83 percent. A patient whose LDL is over 300 usually leaves the clinic with LDL lower than 100.

Penn State Lipid Clinic physicians are available for consultation to help patients and their primary care doctors decide what the most appropriate lipid goals are, and what therapy may be necessary. If action is needed, the clinic has a full range of options to help even the most difficult problems.

Lipid clinic consultations can be scheduled by calling (877) GO-PSHVI.

Robert Zelis is a professor of medicine and cellular and molecular physiology at Penn State College of Medicine and a cardiologist in the Penn State Heart and Vascular Institute (PSHVI). Peter Alagona is an associate professor of medicine and program director, general cardiology for PSHVI.