Get the Most out of Your Cholesterol Medication
How low should my cholesterol go?
When can I lower or stop my drug dose?
How can I lower my drug costs?
These questions are asked of physicians many thousands of times each day. Given the current cost of medications to lower cholesterol they are reasonable questions. Not everyone has an insurance plan that will pay for cholesterol lowering medications, and not everyone can afford or wants to pay a few hundred dollars a year "just to lower my cholesterol". Fortunately, the availability of generic drugs may bring the price down a few pennies. But most of us would rather go to Starbucks and have a nice cup of coffee than go to the pharmacy and rack up a big bill.
But, reducing the bad cholesterol appears to save lives in many scientific trials involving millions of people. In addition, as we lower the cholesterol of the US population, we save lives, and people live longer. When we compare the trials to what we see in the US though, we don't do as well as we should. One of the reasons for this is that we are very strict about dosing in the trials, but not in real life situations. This appears to be due to a sentiment that we should use low doses of medicines rather than high doses. Unfortunately this sense of using "homeopathic" doses, and practicing "holistic" or "integrative" medicine that pander to certain public perceptions are neither sensible, nor based upon any scientific reasoning. I am sure that I will get a negative comment or two about this paragraph, however, the statement stands.
A recent Consumer Reports on Health unfortunately is adopted from an article in the Archives of Internal Medicine from 6 years ago and suggests that patients can "get by" on lower doses of various cholesterol lowering medications, examples are: lowering simvastatin (Zocor) dose from 20 to 40 mg daily to a dose of 10 mg daily, atorvastatin (Lipitor) from 10 or 20 mg to 5 mg, pravastatin (Pravachol) from 40 mg to 5 to 10 mg, or lovastatin (Mevacor) from 20mg to 10 mg. In the same article similar dose reductions were recommended for several medications to lower blood pressure. Despite the wonderful reputation of the Consumer Reports, this particular set of recommendations is just plain wrong and not responsible reporting.
We have observed over the past several years that the good results seen in may trials are not duplicated in the general population. There are several reasons possible for this, including performing the studies in groups of patients that do not reflect the general population or not noting problems associated with the medication (such as side effects) in the original trials. But the major reason that we have found for the population not getting the full benefit that we have expected from trials is failure to follow the dosing that is used in the trial.
In the case of the drugs mentioned above, the reduced doses make no sense whatsoever, as the benefits of the drugs will not be achieved. I have also heard colleagues suggest that the same drugs can be given every other day in an effort to save money. Now I understand the goal of saving money, especially when money isn't flowing in your household, but I have never recommended eating every other day to someone who is in a financial bind. And there is no evidence that the every other day dosing gives the same benefit as an every day medication dose. There is certainly evidence with other drugs that taking less frequent doses leads to less effectiveness and more problems. So, if you do need to lower the drug bills, a long discussion with your doctor about the goal of the therapy is in order.
What are the goals of therapy? We want to achieve a (over a long period of time) cholesterol level that will lead to the longest possible healthy survival of the patient. After much research over many years, starting with the Framingham study and ultimately involving millions of people all over the world, it has become apparent that total cholesterol of under 200mg/dl, and an LDL (the bad portion of cholesterol) under 100 mg/dl should be our goal. In patients however who already have significant arteriosclerosis our current goal is to drive the LDL cholesterol down to 70mg/dl.
So how do we get the price down? Unless the government changes the regulation of drug companies, we try to switch to the least expensive generic equivalent alternative, and have an earnest discussion with your physician about your diet. Losing weight is not expensive, and it works to lower the cholesterol in everyone. Portion control is also less expensive. Yes, you can eat at a good restaurant, take home the food and enjoy it for another meal. That cuts the price in half, and you get twice the enjoyment, and down will come the cholesterol. Really, that is the best way to cut the cost of your medical care.