absorb some other drugs, such as Digoxin, Coumadin and some fat-soluble vitamins, and therefore care should be taken not to administer these drugs at the same time as you would be taking other drugs, such as Warfarin (Coumadin). Another commonly used drug to lower cholesterol when a statin needs more help, or when one cannot tolerate statins, is Ezetimibe (Zetia). This is a new class of cholesterol-absorption inhibitors. This impairs the absorption at the level of the intestine of dietary and biliary-produced cholesterol, the two sources from which cholesterol in our bloodstream arises. Our livers make cholesterol. As with the bile acid sequestrants, Ezetimibe (Zetia) is not as strong in lowering cholesterol as a statin
and probably about 50% as effective also. There was some controversy with several studies as to whether Zetia was really effective. The ENHANCE study involved 720 patients with severe cholesterol disorders that were genetic. The cholesterol in these individuals was well over 500, which is extremely high. The criticism with this study is that the patients were just too advanced and it would be difficult to show if the addition of Zetia to a statin would be more effective than a statin alone. Then there was the possibility of a risk of cancer with Zetia. Two studies – IMPROVE-IT and SHARP – were performed and found no increased risk of incidence of cancer, but there was a trend toward increased cancer deaths. This actually does not make clinical sense and was
believed to be a statistical quirk. Longer-term studies are needed. A recent study with Zetia did not show that it increased cancer risk. Most importantly, Zetia, when given by itself, does not increase the incidence of muscle aches or liver-enzyme elevations above that when one is not taking any drug; that is, if they are on a placebo. However, if it is taken with a statin, Zetia can increase liver-function tests slightly higher than with a statin alone. In Canada, there have been reports of some muscle problems with Zetia by itself. This is extremely rare. This drug is extremely effective in lowering cholesterol with minimal side effects and has a very high safety profile. I am often asked about Vitamin B3, also known as niacin. Niacin could be considered almost like a natural substance since it is one of eight B-vitamins. However, in the doses under which it is
consumed, it is suprapharmacological. One has to watch the blood sugar and the liver functions when niacin is given. However, I know of no single drug that is as effective in raising the good HDL cholesterol as niacin. In fact, studies with niacin have shown that when combining it with a statin, the best effects are seen in actually reversing plaque in the arteries. Some lipid experts have even gone as far as saying that it is almost impossible to reverse coronary plaque without using niacin with a statin in patients with established coronary disease. While statins do not lower the bad LDL cholesterol as well as Zetia or Welchol, the advantages of lowering triglycerides and raising HDL’s make it specifically an advantaged agent in individuals who have low HDL cholesterol and high triglycerides. The latter is often seen in diabetics who are overweight. Therefore, if you have elevated cholesterol
and your doctor feels that it needs to be lowered but diet is not effective, one should consider these alternate agents, especially bile-acid sequestrants such as Welchol or intestinal-absorption inhibitors such as Zetia. Zetia is practically free of side effects. The major side effect one occasionally sees with bile-acid sequestrants is a little bit of belching, bloating and constipation, which can be relieved by adding psyllium muciloid (Metamucil). The latter will also naturally lower cholesterol, as it is a soluble agent. Nicholas DePace is a Clinical Professor of Medicine and Associate Chief of Cardiology at Drexel Medical College, Hahnemann Hospital, Philadelphia. He has written a book on how to reverse heart disease, published by W.W. Norton, and he has experience and expertise in lowering cholesterol using different approaches. He is board-certified in lipidology, which is the study of lipid dis-
The Public Record • September 10, 2009
(Cont. from Page 16) and follow them periodically on this medication. While these agents are half as effective as statins in lowering cholesterol (that is, they may lower cholesterol only 50% of what a statin would do), they are probably safer and have fewer side effects. In fact, Welchol has been approved to lower the hemoglobin 1Ac, a reflection of glucose control over a long period of time in diabetics, by the FDA in individuals who do have diabetes mellitus. Generally, it can lower the hemoglobin 1Ac by 0.5%. Some side effects of the bile acid sequestrants are bloating and G.I. discomfort, however with the newer agents, these are much less common. They also can be given in conjunction with many other medications. However, they may appear to
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DePace Explains Why Some Statins Are Better Then Others
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