When a cardiologist friend of mine, practicing in the US, was on a visit to Goa two years ago, he had hinted that we would soon have a magic bullet to further bring down bad cholesterol levels in the bloodstream on patients who were on statins but did not manage to achieve set targets. Eventually, in the May 14, 2014 issue of the Journal of the American Medical Association, researchers after completing all trials disclosed that they had discovered a new injectable drug that could further knock down cholesterol levels in people who were on cholesterol-busting statin medications. People taking the new therapy, alongside statins, enjoyed a 63 to 75 percent decrease in their ‘bad’ (LDL) cholesterol levels, on top of the reduction caused by the traditional statin medications. The new drug named “evolocumab” belongs to the class of drugs known as “human monoclonal antibodies” that, in a roundabout way, improve the body’s ability to remove cholesterol from the bloodstream.
It was always felt that statin therapy alone was often insufficient for patients with high cardiovascular risk and elevated cholesterol to reach optimal LDL cholesterol levels. “Evolocumab”, given in injectable form, has now shown promise. Because it is a very specific drug, it is well tolerated, without any drug interactions or side effects. It is particularly helpful in treating people with a “genetic disorder” where cholesterol levels are sky-high. This marvelous drug could also help people with high cholesterol who can’t take large recommended doses of statins, estimated at 10 percent of people with heart disease or diabetes.
Although the AHA (American Heart Association) task force tried to simplify lipid management by emphasizing statin use, the guidelines acknowledged the limits of statin therapy. Subsequently, the researchers recommended diverse non-statin therapies to improve outcomes in patients having inadequate response to statins. This guidance is likely to require reevaluation, given the large LDL-C reductions produced by “evolocumab”.
Cost considerations will also require appraisal. Further, the real question will be whether decreasing cholesterol levels with this medication is going to make a difference in preventing cardiovascular events since to date there are no long-term prevention trials with “evolocumab”. But, just like with statins, there is much optimism that bad cholesterol reduction with “evolocumab” will further keep strokes and heart attacks at bay.
The new drug, though, may not be for everybody because of its cost. But it is going to be very important for people with “genetic” cholesterol disorders and those unable to take large doses of statins.
As “evolocumab” can get cholesterol levels down to as low as 30 or 40 mg, what happens to those who get these “super-duper” levels? Since there is so much talk about the dangers of high cholesterol, the question arises, “Can low cholesterol levels be equally bad?”
Indeed the fact that high total cholesterol levels are bad is a no-brainer: – too much of this “wax-like” substance in the blood, leads to atherosclerosis, (heart disease, or stroke). But compared to high cholesterol, “low cholesterol” is pretty much off most people’s radars! While there are no two opinions about the salutary effect of reducing high cholesterol as a strategy for preventing or treating heart disease, there is much less agreement on how (or whether) to respond to “very low cholesterol levels”.
Do we need to worry if cholesterol levels dip too low? From the standpoint of heart health, probably not. On the other hand, unusually low levels of cholesterol could undermine the body in other areas, including the brain and digestive system. So, it is good to remember that healthy cholesterol levels seem to follow one of life’s major rules: “avoid extremes”.
As I was researching for this article, I found what an observant and sharp-eyed doctor had to say. He asks, “Are we being misled about how bad cholesterol is? Obviously, heart disease is one of the leading causes of death. But, half of hospitalized heart attack victims I treat”, the doctor reasons out, “have normal cholesterol levels”. He adds, “Unfortunately a lot of politics seems to be involved here. Since both drug companies and food companies have much to gain — and much to lose — studies and governmental guidelines and regulations are subject to corruption”, he laments. “Do drug companies who sell cholesterol lowering drugs want everyone to believe that cholesterol is bad, and that your cholesterol level should be as low as possible, so they can sell more cholesterol lowering drugs?” Finally, as a watchdog within the medical profession (and there are few of them nowadays!), the maverick doctor demands to know, “What is the truth so that I too can avoid heart disease?”
Conceding that the concerned doctor’s observations have a grain of truth, let us be reminded that cholesterol is not the only risk factor causing heart attacks. The genesis of a heart attack is multifactorial. However, cholesterol does play a major role in triggering heart attacks and strokes. Anyone who willingly chooses to ignore the results of hundreds of cholesterol studies will do it at his own risk.
Dr Francisco Colaço is a seniormost consulting physician
