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I Could Be Wrong

I Could Be Wrong

More people would learn from their mistakes if they weren’t so busy denying them.

— J. Harold Smith

I’ve been struggling with the lack of humility on the side of the White House, the media, and the voting public throughout the Covid Pandemic. But, it’s the inability of my colleagues on the clinical side of medicine and the bench top scientists to say “we could be wrong,” or better still – “we will be wrong” – as we’ve navigated this unprecedented pandemic that has bothered me the most. Which is why I was grateful for the tense moment during a consult with a patient of mine today. His remarks reminded me that the unreasonable expectations about healthcare in America during the pandemic started long before SARS Cov-2 ever arrived on our shores.

Despite a major improvement in his sleep and a reduction in his overall inflammation (CRP) my patient’s LDL-particle number (that’s what you should worry most about) was up 10% from the prior year. He was now challenged with moderately high levels and we needed to improve his treatment plan.

He and I would later tease out that his increased evening alcohol intake was likely the culprit. But, when he heard the news about his cholesterol he, nevertheless, wasn’t happy – “you told me last year that a high LDL didn’t matter if my LDL particles were the large and buoyant type – which they are.” He was right. I did tell him that. And what I told him turned out to be…wrong.

I told him that the size mattered more than the LDL number a year ago, because that was what most lipidologists thought – at the time – was true. Since then we’ve gained additional insight and it turns out that size doesn’t really matter when it comes to assessing LDL cholesterol’s contribution to cardiac risk.

Scientists used to believe that the number of passengers in the car (i.e. concentration of cholesterol in the LDL particle) is the driving factor in the development of heart disease. More recent studies, however, suggest that it’s the number of cars on the road (i.e. LDL particles) that matters most.

— Chris Kresser, MS

(If you’re wondering if a person can have a “normal” total LDL or LDL-C, but have a dangerously high LDL-P – particle number – the answer is – yes. I have six cases in my practice.) It’s the number of particles, not the size that matters to one’s risk for atherosclerotic disease. But, we could be wrong. Next year we might discover that particle size is a more significant contributor to disease. That’s an inconvenient truth about medicine that we doctors aren’t encouraged to convey to our patients. Instead, modern medicine – and the context of modern society’s legal expectations – has restricted itself to a limited number of protocols with the lowest chance of stimulating a lawsuit. Want another example of getting it wrong as it relates to cholesterol? Of course you do.

The Cleveland Heart Lab blood panel makes risk stratifying for coronary disease more reliable by adding inflammatory markers to the lipid particle assessment.

When I was finishing medical school I remember our cardiology professor telling us that “statins are so good for people that they will one day be in the water.” He and many others believed statins, like Crestor and Lipitor, would both reduce cholesterol and greatly improve overall blood vessel health (endothelial function). The science behind statin drugs was strong. And five years later The Jupiter Trial, which showed a 20% reduction in all-cause mortality in those who used rosuvastatin would support my professor’s claim. But, then the side effects came out.

Close to one in five patients had lower energy and muscle fatigue, called myalgias, on statins. Within five
years it was discovered that statins robbed the body of CoQ10, an essential co-enzyme for energy production. A black box warning was added to the package insert recommending CoQ10 supplementation while on the drug. Suddenly statins were the enemy. A few years later an increased risk for type 2 diabetes was added to the statin side effects list and the anti-statin campaign was in full swing.

Cardiologists and PCP’s didn’t stop writing for statins, however and those of us on the preventive medicine side started to question the ongoing reflexive prescription writing that was happening. Sure an LDL under 120 (that’s LDL-C, or calculated, not LDL-P, Particle number) was good, but did it really need to be 60 ? I started to notice a concerning trend among those men taking statins who had extremely low LDL’s. They also had very low testosterone.

One of the many good things cholesterol does for the body is fuel the production of sex and stress hormones. Yes, the body makes cholesterol for good reasons. In balance the side effects of statins made it seem like getting patients off statins was a noble mission – up until about six months ago.

The core predicament of medicine – the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of society that pays the bills they run up so vexing – is uncertainty.

— Atul Gawande, Complications: A Surgeon’s Notes on An Imperfect Science

It was then that I learned — through my work with Cleveland Heart Lab — of a growing number of success stories in patients using micro-doses of statins. This new strategy didn’t apply to those with bad familial hypercholesterolemia, but several patients with elevated LDL particle numbers (LDL-P) were getting a significant reduction in LDL with the lowest dose of Crestor (5mg) taken as little as once per week.

Furthermore, we now understand that most of the statin side effects go away if you correct underlying thyroid disease; normalize vitamin D levels, and supplement with CoQ10 ( I like 300mg/day for patients who are on a statin.)

I’ve come to realize that pharmaceuticals in America are generally launched with “evidence-based guidelines” at dosages that are unnecessarily high. The drug companies recommend high doses in an attempt to show extremely high response rates. But, that means many people are often over-treated and there’s a need for that last fifteen seconds of a drug commercial to list a horror show of potential side effects. So, this “correction” in statin therapy dosing is something that should be kept on radar for other prescription drugs, like anti-hypertensives and compounded prescriptions, like estrogen and testosterone, as well.

The trade-off for optimizing your bio-individual need for a particular drug – that is the dose where you get the desired therapeutic response with the least side effects – is more frequent lab testing and more frequent communication with your doctor. If you’re willing to do those two things then your chance for success is high.

But, I could be wrong.

Sincerely,

Adam Miller, DDS, MD (an imperfect dentist and physician)
Medical Director, ARISE MD

For more information about Cleveland Heart Lab testing and the entire heart-smart prevention plan at ARISE MD, please email: info@arisemd.com OR call: 414 386-2600.

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