Dr. Paul D. Thompson, MD, describes the pitfalls he has run into when treating high cholesterol with statins: how long treatment lasts, worry about side effects, starting doses that are too high, and what doubling a dose really adds.
Starting a Statin: Lifelong Treatment, Side Effects, and Dose
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- Why he tells patients treatment is lifelong
- Reassurance about side effects
- A quick effect and early measurement
- Starting with low doses
- The statin rule of six
- Full Transcript
Why he tells patients treatment is lifelong
How long treatment lasts is the first pitfall Dr. Paul D. Thompson, MD, describes when Dr. Anton Titov, MD, asks about common problems in treating high cholesterol. Some patients, he says, think a statin is like penicillin for an infection, taken for 14 days. He always tells them they will take it for the rest of their life, unless something happens to them that needs treatment.
Reassurance about side effects
Side effects are the next point. Patients will read about them in the popular media, so Dr. Thompson reassures them that side effects are very rare. He says only about five percent of people treated with statins get any sort of muscle complaints, which he calls quite an unusual side effect.
A quick effect and early measurement
The speed of the statin effect is something patients also need to know, in his view. He says the maximum effect comes at about two weeks, so he likes to get measurements soon after starting a statin. Seeing a quick improvement provides positive reinforcement, and because the change happens so fast, patients understand it must be the medication.
Starting with low doses
Starting patients on the maximum or a very high dose is another common pitfall, according to Dr. Thompson. He says the maximum reduction per milligram comes with very low doses, a point he finds hard for clinicians to understand.
His example is rosuvastatin, whose usual recommended starting dose is one five-milligram tablet daily. His group showed that giving patients five milligrams only on Monday and Thursday produced a 27% reduction in LDL cholesterol.
The statin rule of six
The statin rule of six is his name for the last pitfall. Starting a statin gives about a 25 to 35% LDL reduction, he says, but doubling the dose does not repeat that effect. It adds only about six percent more reduction.
He closes with the points he wants patients to understand: treatment is lifelong, side effects are very rare despite what they read, the statin rule of six applies, and treatment starts with low doses.
Full Transcript
Dr. Anton Titov, MD: Care of patients with high cholesterol, common pitfalls in cholesterol treatment. You have treated patients with high cholesterol and heart disease for decades. Your blog shares rules of cardiology from your clinical practice. Professor Thompson, what are the most common pitfalls in the treatment of high cholesterol? What should every patient know before the first statin?
Dr. Paul D. Thompson, MD: So what are the common pitfalls of treating high cholesterol? That is a tough question. Let me give you a couple of things that I have run into over the years.
Dr. Paul D. Thompson, MD: First of all, the patients do not know how long they are going to be treated. Some people think it is like penicillin for an infection: you are going to take it for 14 days. So I always tell them, you are going to take it the rest of your life unless something happens to you that we need to treat.
Dr. Paul D. Thompson, MD: The other thing is reassuring the patients about the fact that they are going to read about side effects in the popular media, but that side effects are very rare. We find that only about five percent of people treated with statins actually get any sort of muscle complaints, and that is quite an unusual side effect. I think they also need to know that the effect is very quick.
Dr. Paul D. Thompson, MD: When we start somebody on a statin, the maximum effect of that drug is actually about two weeks. So we like to get measurements pretty quickly after starting someone on a statin, because that provides positive reinforcement. The patients can see, "Oh look, I have gotten a lot better." Even the patient who is not that intelligent understands that it must be that drug, because it happened so quickly.
Dr. Paul D. Thompson, MD: The other thing I think is a common pitfall is that a lot of clinicians will start patients on the maximum or very high dose of the drug. It is hard for doctors and clinicians to understand, but you get the maximum reduction per milligram of drug (and that is very important, per milligram of drug) with very low drug levels. Let me give you an example.
Dr. Paul D. Thompson, MD: The usual dose of rosuvastatin is five milligrams, one five-milligram tablet daily. That is the usual recommended starting dose. We showed that by giving patients five milligrams only Monday and Thursday, they got a 27% reduction in LDL cholesterol.
Dr. Paul D. Thompson, MD: The other thing to remember, the other pitfall, is what I call the statin rule of six. When you double the dose of a statin, you only get about a six percent additional reduction. When you start a statin, you get about a 25 to 35% LDL reduction.
Dr. Paul D. Thompson, MD: When you double that dose, you do not get another 25 to 35% reduction. You get only a six percent reduction. So I think those are some of the pitfalls.
Dr. Paul D. Thompson, MD: Making sure that the patient knows that this is lifelong treatment. Making sure that you reassure the patient that they are going to read a lot about side effects, but they are very rare. Making sure they understand the statin rule of six, and you start with low doses.