Options for Cholesterol

Senior man jogging for good health

A patient who has made significant personal progress welcomes a visit to a new physician but becomes disillusioned by an insistent recommendation.

Painful History

All that the patient we call Thomas wants is to feel better as he ages. For over five years, myalgic and neuropathic pain disabled him, unable to walk for longer than 15 minutes at a time even with great effort. The mere act of getting up from bed required an extra-strength pain reliever. On occasions when more stamina was required, he resorted to prescription opioids. A pain management doctor even injected cortisone in his back to dull the nerve receptors. His lack of mobility added 30 pounds to his body weight.

It was a physical and mental relief when the medical team within his new health plan, with more modern equipment, was able to diagnose and treat the underlying problem. The pain-relieving prescription has since expired and the use of over-the-counter NSAIDs is no more than the average person.

The issue that remains is his excess weight. For this, he has embarked on a high-tech approach, purchasing a fitness-motivating wristwatch. He also makes some adjustments to his meal portion size. Happily, he drops 15 pounds. It’s now time for his annual physical with a new internist, Dr. Ayako.

Examining Symptoms

Within the small examination room, his massive appearance casts a shadow on the petite nurse who enters to record his vitals. He steps on the scale, proud of the progress, though still far off from his goal. She then inputs his normal body temperature, slightly elevated blood pressure, and normal blood oxygen level. Nurse Julie says “Your doctor will see you shortly,” with a smile.

It’s difficult to summarize years of medical history within 30 minutes. Thomas wonders where to begin. Fortunately, his diminutive young physician, whom we’ll call Dr. Ayako, has reviewed available medical records in advance and listens intently to the patient looming two-and-half times her size. At six-foot-four inches and 250 pounds, it’s easy to assume he indulges in fatty foods. With no double chin, he carries most excess weight in his midsection measuring in the low 40 inches, though it’s flattening.

Thomas raises concerns about the elevated heart rate alerts from his digital watch. He is also due for a colon cancer test. Dr. Ayako listens to his heartbeat through her stethoscope, shines a light in his eyes, and types notes into the computer. Before exiting, she indicates that she wants to see an EKG and a comprehensive blood panel.

Nurse Julie returns after the consultation, asking Thomas to put on an upper paper gown, open in the front for the EKG. When she leaves to get the equipment, he puts on what looks like a woman’s crop top. The EKG is normal. She then fills vials with his blood for all the testing and hands him a stool sample kit to use at home for the colon cancer screening.

Test Results

With medical records linked to the health app on his phone and wristwatch, Thomas receives alerts in real-time. The dozens of numbers coming in for several weeks from numerous lab tests are surprising. Nearly all report normal ranges. His vitamin D is one-third of what doctors consider the minimum.

Cholesterol levels tend to increase with age. An overall reading between 200 and 239 mg/dL is considered borderline high and a reading of 240 mg/dL and above is considered elevated. Although his total calculated cholesterol is 181, his good cholesterol (HDL) is low and his bad cholesterol (LDL) is high.

A standard target for the LDL varies based on medical history. A general rule is below 100. Patients with previous heart events or diabetes may strive to get the number below 70.

Over ten years, Thomas has seen his overall cholesterol range between 163 and 201 So his current result of 181 is not the best, but not the worst either. Generally, an elevation can be traced to binging on unhealthy snacks, although the majority of meals are healthy.

Without statins, his HDL has ranged between its current low of 38 and 45, where 40 or above is optimum. His LDL has been as low as 91 and as high as 143, but now it’s 119 using the Martin-Hopkins calculation method. (Cholesterol/HDL ratio is within range at 4.8. Non-HDL cholesterol is 13 mg above optimum.)

Prescription Concern

The day after reviewing these reports, he receives a text alert notifying him that his prescription for a statin is ready for pickup from the pharmacy. A note on his medical record indicates that the physician wants to see his LDL below 70.

By this standard, his variable LDL cholesterol of 119 seems extremely elevated, but he is not a heart patient. The resting heart rate has decreased by 20 beats per minute on average since his medical exam, as a result of his daily walking. He also shed another 5 pounds.

Thomas inquires about a vitamin D prescription. This is a chronic issue for him, exacerbated by a lack of sunlight from an office job and a vegetarian diet absent of fatty fish. A prior physician prescribed twelve weekly D3 doses of 50,000 units (1,250 mcg) followed by daily D2 units of 2,000 (50 mcg). Within four months, this brought total D levels to about 24—still shy of the 30 thresholds and much lower than the 100 optimum upper level.

Thomas passes this information along to his new doctor through a medical text message portal. She more conservatively prescribes 50,000 units of D3 for eight weeks followed by daily D2 units of 1,000 (25 mcg).

Effects From Too Little Vitamin D

A longstanding concern of vitamin D deficiency is brittle bones. Clinical studies now reveal that very low vitamin D levels can raise cholesterol and cause heart problems. To Thomas, who has been working with derma-pharmaceutical scientists for over 30 years, this suggests that raising his vitamin D level should be the primary concern over beginning statins.

Something else that concerns him about statins is that according to different reports, 25–29 percent of patients with such prescriptions are noncompliant due to myalgia. Joseph A. Hill, M.D., Ph.D. Puts the number lower for his patients, estimating 10 percent. About in 10,000 of those develop rhabdomyolysis, with possible kidney damage.

With it being less than two years since overcoming his debilitating handicap, Thomas doesn’t want to risk returning to that state with a prescription. He is also awaiting a second surgery to remove kidney stones, as the primary cause of his prior chronic pain.

The cautious patient suggests to Dr. Ayako that he continue losing weight with aerobic exercise and cut down on fatty snacks while taking vitamin D along with magnesium, another supplement known to reduce cholesterol. However, Dr. Ayako doubles down, revising her recommendation on the file, now indicating that Thomas should aim for an LDL below 100 with her prescribed statin.

Medical doctors learn to treat illness with medicine, not vitamins, per se. So it is not shocking for a physician to focus on an evidence-based prescription. The longstanding patient LDL above 100 is also difficult to ignore. Because Dr. Ayako is part of a medical group, there may be requirements to take specific actions in response to standard guidelines.

However, it is surprising that there is little consideration for other factors that have been elevating the cholesterol, or the steps already underway to reduce it.

Challenging Recommendations

As a patient, perhaps you empathize with Thomas, feeling the frustration of the risk-benefit dilemma. As a physician, the notion that a patient would dare to question the efficacy of scientific recommendations may be absurd. In defense of vast medical education, doctors wielding the power of prescription pads can impose upon the free will of patients. A non-compliant notation of medical records impacts future care by other physicians.

To a doctor, a prescription error becomes a learning experience within the profession called a practice. To the patient who must cope with a debilitating outcome, it’s a life-altering event of inconvenience.

Perhaps you feel Thomas should fill the prescription and report any side effects if they occur. But, he has endured nearly a dozen personal examples of misdiagnosis with adverse consequences. His file includes several detrimental drug reactions. Realizing the sensitivity of his own body has made him more cautious about accepting drugs with possibly severe side effects.

With the realization an incompatibility with magnesium exists, he chooses to avoid statins, as he’s done in the past, improving his cholesterol levels. He dropped his overall cholesterol level from 200 to 173 within 8 months using this method.

Better Health

Something else he’s done to improve his long-range outlook is to subscribe to a healthy meal kit delivery service. After specifying preferences, he sees a weekly meal plan with balanced servings that provide optimum nutrition with less than 30 minutes of cooking time.

During the three-month follow-up exam, he expects a decrease in LDL cholesterol, although it might not yet reach below 100, given the short time frame and low vitamin D levels.

The main challenge is a consistent routine. Advantages in his favor include the investment in monitoring technology and healthy meal planning. So he prepares for a future in-person exam when he will focus on elevating vitamin D levels as a means to lower cholesterol. In the interim, he’s thankful that he has the mobility to continue surpassing weekly fitness goals.

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To support the writing of useful articles about internist, ClinicalPosters sells human anatomy charts, scientific posters, and other products online. You may sponsor specific articles or remit a small donation.

ClinicalPosters sells human anatomy charts, scientific posters, and other products online to offset expense of the writing useful articles about internist. Slide extra posters into DeuPair Frames without removing from the wall.

ClinicalPosters sells human anatomy charts, scientific posters, and other products online. You may remit a small donation.

You can support the writing of useful articles about internist by sponsoring specific articles or remitting a small donation.

This article uses fictitious names.

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