When Your Doctor Orders Cholesterol-Lowering Medications

When Your Doctor Orders Cholesterol-Lowering Medications
Do you really need statins to lower cholesterol?
By Gina Shaw
Reviewed by Brunilda Nazario, MD

You’ve just left your doctor’s office with a prescription for a statin medication to help lower your cholesterol. But you may be nervous. You’ve heard that you’ll have to take this cholesterol-lowering medication for the rest of your life. And your doctor noted that statins, like all medicine, can cause side effects.

Why should you take a statin? Can’t you just improve your cholesterol levels by eating right and exercising? The answer is yes -- and no. Healthy cholesterol and triglyceride levels look like this:

Total cholesterol: less than 200 mg/dL

HDL (“good” cholesterol): 40 mg/dL or more for men, 50 or more for women

LDL (“bad” cholesterol): less than 130 mg/dL

Triglycerides: less than 150 mg/dL

Many people can get their cholesterol and triglyceride levels into these healthy ranges through a combination of a healthy diet and an active lifestyle. But for many others, these lifestyle changes help, but are not enough.
Measuring the Benefits of Statins, Diet, and Exercise

“Lifestyle changes certainly are the cornerstone of cholesterol reduction,” says Michael Miller, MD, director of the Center for Preventive Cardiology at the University of Maryland Medical Center.

Exercising, eating a healthy diet, and losing weight can result in:

* A 5% to 10% reduction in LDL cholesterol
* A 10% to 30% reduction in triglycerides

But for those with very high LDL cholesterol or triglycerides, those lifestyle measures may be insufficient. “If your lipid levels are way out of whack, for example, reducing your LDL by 10% may not get you down to a healthy level,” Miller says.

* Statin medications act quickly and can help reduce LDL or “bad” cholesterol by up to 50% or more.
* Statins also help increase HDL or “good” cholesterol by up to 15%.

If you’re making healthy lifestyle changes at the same time, says Miller, you should see major changes in your cholesterol levels within two to four weeks after beginning lipid-lowering therapy.

“Statins are very simple: you take them once a day, and their effects are quite profound,” says Patrick McBride, MD, MPH, director of the preventive cardiology program and the cholesterol clinic at the University of Wisconsin School of Medicine and Public Health.

“Not only do statins improve your cholesterol levels, but they reduce your risk of heart attack, stroke, and cardiovascular events. They’re one of the great success stories of modern medicine,” says McBride.

Most recently, the JUPITER trial showed that statins can also slash the risk of heart attack nearly in half for people with normal cholesterol but high levels of a protein associated with inflammation.
Statin Side Effects and Other Worries

What about side effects from taking statins? It’s true that any medication comes with side effects. Side effects most commonly seen with statins are headache, GI tract upset, muscle and joint aches, or rash. Very rarely, patients may experience muscle or liver damage.
Statin Side Effects and Other Worries continued...

Overall, however, the risks of statins are low. “They’re less than the risks associated with taking two aspirin a day,” says McBride. The benefits are well established, with hundreds of thousands of people studied in clinical trials. The benefits enormously outweigh the risks for the right person.”

In fact, although there is a very small risk of liver damage from statins, McBride notes that many other people see a benefit to their liver after taking statins, because they had previously built up fat or triglycerides in the liver, which can lead to inflammation and damage.

When there is liver damage or muscle weakness because of the use of statins, those side effects all reverse themselves when the patient stops taking the statin.

What about the idea that you’ll have to take statins for the rest of your life? That’s the wrong way of looking at it, McBride says.

“I have very few patients who stay on the same medications for five years, let alone the rest of their life,” he says. “New medications and new options will come along. You’ll change. We’ll change. For the near term, you will be on statins every day, but as new things develop, we’ll adapt.”
Questions to Ask Your Doctor About Cholesterol Medication

If you’re concerned about why your doctor has prescribed statins to lower your cholesterol, here are a few questions to ask:

* Why do you think I’m a good candidate for this medication?
* What will this do for me and my body?
* What are the potential benefits versus the risks to me specifically?
* Will this have any interactions with anything else I’m taking? (Be sure to tell our doctor if you’re taking over-the-counter medications or supplements. Several supplements can interact with statins.)
* What are the long-term goals of therapy?
* Can I take a supplement instead of a statin to lower my cholesterol?
* Will supplements interfere with the effects of the statin?

Miller tells his patients to look at statins as they would a vitamin to boost health. “In many ways, that’s what it is,” he says, “and it’s the only one that we know that works so well to improve cholesterol and lower cardiovascular risk.”


SOURCES:

Michael Miller, MD, director, the Center for Preventive Cardiology, University of Maryland Medical Center, Baltimore.

Patrick McBride, MD, MPH, director, preventive cardiology program and cholesterol clinic, the University of Wisconsin School of Medicine and Public Health, Madison, Wis.

American Heart Association, Atlanta.
Reviewed on December 30, 2008

Drug Errors Common in Chemo Treatments

Drug Errors Common in Chemo Treatments
Improved Communication May Be Best Method to Prevent Mistakes
By Bill Hendrick

Reviewed by Brunilda Nazario, MD

Jan. 1, 2009 -- A new study shows that medication errors are common among children and adults taking chemotherapy drugs at home or in outpatient clinics.

Researchers reviewed records of nearly 1,300 patient visits at three adult oncology outpatient clinics and 117 patient visits at one pediatric facility between Sept. 1, 2005, and May 31, 2006.

They showed that 7% of adults and 19% of children taking chemotherapy drugs in outpatient clinics or at home were given the wrong dose or experienced other medication mistakes.

The study, published in the Journal of Clinical Oncology, calls for improved communication to cut down on errors it describes as "high" in adult and pediatric cancer patients.

Of the errors involving adults, 55 had the potential to harm the patient, and in 11 instances, harm was caused, the researchers say.

About 40% of the medication errors in children had the potential to cause harm, and four children actually were harmed by mistakes, the study shows.

In a news release, Kathleen E. Walsh, MD, assistant professor of pediatrics at the University of Massachusetts Medical School, says that as cancer care increasingly shifts to outpatient settings, the potential for errors goes up correspondingly.

More than 70% of errors in children occurred at home, says Walsh, the study's leader.

Examples of pediatric errors included giving the wrong amount of medication or giving it at the wrong frequency because of confusion about instructions.

The mistakes in adults included the administration of incorrect doses because of confusion over conflicting orders. Consequences of mistakes included patients being overhydrated prior to giving chemotherapy and abdominal pain in patients taking narcotics without treatment for constipation.

The researchers say more than 50% of errors involving adults were in clinic administration, 28% in ordering medications, and 7% in use of chemo in patients' homes.
Why Medication Mistakes Happen

"As cancer care shifts from the hospital to the outpatient setting, adults and children with cancer receive more complicated, potentially toxic medication regiments in the clinic and home," Walsh and colleagues write in the article.

According to the researchers, methods to prevent outpatient medication mistakes often fail because of a lack of recognition of errors, communication problems, and fragmentation of care.

Chemotherapy regimens outside of clinical settings are "particularly complex because of the intense monitoring required" and a plethora of potential problems made more likely when drugs are taken in a non-clinical setting, they write.
Preventing Medication Errors

"Information technology such as computer order entry, electronic medication administration records and bar-coding used to prevent errors in the inpatient setting may be particularly important in outpatient clinics where multiple oral and intravenous medications are administered, such as in an oncology clinic," the researchers contend.

One simple strategy to reduce errors: requiring that medication orders not be written until the day of administration, the researchers suggest.

Walsh says in the release that most errors involving children could be reduced "by better communication and support for parents of children who use chemotherapy medications at home."
View Article Sources Sources

SOURCES:

News release, University of Massachusetts Medical School.

Walsh, K. Journal of Clinical Oncology, published online ahead of print Dec. 29, 2008.

When should you get a bone density scan, and why?

Bone Scans and Bone Health Screenings
When should you get a bone density scan, and why?
By Matthew Hoffman, MD
Reviewed by Celia E. Dominguez, MD

A bone density scan can detect thinning bones at an early stage. If you already have osteoporosis, bone scans can also tell you how fast the disease is progressing.

But an abnormal bone scan can create as many questions as it answers. Who should get a bone density scan, and what do the results mean? If your bone density is below normal, what can you expect, and what should you do?
A Date With DEXA

Most bone scans use a technology called DEXA (for dual energy X-ray absorptiometry). In a DEXA scan, a person lies on a table while a technician aims a scanner mounted on a long arm. (Think of the machine that X-rays your teeth at the dentist; the difference is that this test uses very low energy radiation.)

"DEXA currently is the easiest, most standardized form of bone density testing, so that's what we use," says Mary Rhee, MD, MS, an endocrinologist and assistant professor of medicine at Emory University in Atlanta.

The DEXA scanner uses beams of very low-energy radiation to determine the density of the bone. The amount of radiation is tiny: about one-tenth of a chest X-ray. The test is painless, and considered completely safe. Pregnant women should not get DEXA scans because the developing baby shouldn’t be exposed to radiation, no matter how low the dose, if possible.

Measurements are usually taken at the hip, and sometimes the spine and other sites. Insurance or Medicare generally pays for the test in women considered at risk for osteoporosis, or those already diagnosed with osteoporosis or osteopenia.

Other less commonly used technologies can measure bone density. They include:

* Variations of DEXA, which measure bone density in the forearm, finger, or heel.
* Quantitative computed tomography (QCT). Essentially a CAT scan of the bones, QCT provides more detailed images than DEXA.
* Ultrasound of the bones in the heel, leg, kneecap, or other areas.

While all of these can determine bone density and osteoporosis risk, "DEXA is the most important test and is the gold standard," says Felicia Cosman, MD, clinical director for the National Osteoporosis Foundation.
Interpreting Your DEXA Bone Scan Results: T-Scores and Z-Scores

DEXA scores are reported as "T-scores" and "Z-scores."

* The T-score is a comparison of a person's bone density with that of a healthy 30-year-old of the same sex.
* The Z-score is a comparison of a person's bone density with that of an average person of the same age and sex.

Lower scores (more negative) mean lower bone density:

* A T-score of -2.5 or lower qualifies as osteoporosis.
* A T-score of -1.0 to -2.5 signifies osteopenia, meaning below-normal bone density without full osteoporosis.

Multiplying the T-score by 10% gives a rough estimate of how much bone density has been lost.

Z-scores are not used to formally diagnose osteoporosis. Low Z-scores can sometimes be a clue to look for a cause of osteoporosis.
DEXA Bone Scans: What Your T-Score Means

Being told your bones are thin is cause for concern, but not alarm. If your T-score is low, what can you expect?

First of all, unless you're a woman past menopause or a man older than 50, your risk of fracture is very low. In these groups, even with a T-score less than -2.5, bones are usually strong and treatment isn't recommended.

On the other hand, if you've been told you have osteoporosis, take it seriously. Feeling fine is no protection at all: fractures of the spine can be silent and painless. "Anyone with osteoporosis should be on some kind of treatment," according to Baker.

For those with osteopenia (T-score between -1.0 and -2.5), the picture gets confusing. It's harder to predict fracture risk in this group of people. Focusing too closely on the T-score can be a mistake. "The DEXA T-score is not a perfect predictor for bone health or fracture risk," says Rhee.

Actually, bone density (measured by T-score) is only one aspect of fracture risk. Your risk factors (see above) can be just as important. Using both the T-score and risk factors for fracture leads to better predictions.

The World Health Organization is developing a formula using risk factors in combination with the T-score to determine 10-year fracture risk. "We'll probably see this coming into use in the next few years," says Rhee.
Bone Scan T-Scores: When It's Time to Treat

The National Osteoporosis Foundation recommends treatment for:

* Postmenopausal women with T-scores less than -2.0, regardless of risk factors.
* Postmenopausal women with T-scores less than -1.5, with osteoporosis risk factors present.

In addition, anyone with a fragility fracture (a fracture from a minor injury) should be treated for osteoporosis. This is true regardless of the DEXA scan results.

Treatment generally begins with a bisphosphonate medicine (Actonel, Fosamax, or Boniva). These drugs are proven to increase bone density and reduce the risk of fracture. Other options include:

* Estrogens (hormone replacement therapy)
* Calcitonin
* Teriparatide
* Raloxifene

In addition, the National Osteoporosis Foundation recommends 1,200 milligrams of daily calcium intake -- through diet and/or supplements.
When Should You Get a Bone Density Scan?

When, and how often, you should get a bone density scan depends on your age, risk factors, and whether you’ve already been diagnosed with thinning bones.

The general rule: anyone at risk for osteoporosis should get a bone density scan. Don’t wait for a fracture or a formal diagnosis.

Postmenopausal women are at highest risk, because estrogen (which falls after menopause) preserves bone strength. But men get osteoporosis, too. "They just get it later," says Mary Zoe Baker, MD, an endocrinologist and professor of medicine at the University of Oklahoma Health Sciences Center. Usually around age 70, "men start to catch up to women" in developing osteoporosis, according to Baker.
When Should You Get a Bone Density Scan? continued...

Major expert groups make the following recommendations for osteoporosis screening and bone scans:

Women over age 65: All women over the age of 65 should get a DEXA scan, according to the National Osteoporosis Foundation and the U.S. Preventive Services Task Force.

Postmenopausal women under age 65: For women under 65, a bone scan is not universally recommended. The National Osteoporosis Foundation recommends a bone scan for women with risk factors for osteoporosis:

* History of bone fracture as an adult
* Current smoking
* History of ever taking oral steroids for more than 3 months
* Body weight under 127 pounds
* Having an immediate family member with a fragility fracture (a broken bone from a minor injury, suggesting osteoporosis).

Premenopausal women: Generally, premenopausal women should not get bone scans. Even with an abnormal DEXA scan, the risk of fracture is still very low, and treatment isn't recommended. "The No. 1 rule is, don't get the test unless you know you're going to treat" if the result is abnormal, says Baker.

Men: Experts differ in their recommendations for bone scans for men. The National Osteoporosis Foundation recommends all men over the age of 70 should get a bone scan. At that age, "many men are on their way to developing osteoporosis," says Cosman.
Bone Scans for Osteoporosis: How Often?

If you've been told you have thin bones, you'll want to know if they're improving or getting worse over time. How often should a bone scan be done?

Medicare and many insurance companies will pay for a bone scan every two years in women with osteoporosis or who are at high risk. Because the response to treatment occurs slowly, this is usually an acceptable time interval, according to Rhee.

"In cases with high bone turnover rates, like women taking high-dose steroids," checking bone density as often as every six months may be necessary, says Rhee.

For women with a normal bone scan, waiting a few years to retest is fine, adds Rhee.

Another thing to keep in mind: not all DEXA scanners are created equal. There are slight differences in the calibration of different manufacturers' machines. Ideally, you should get all your bone scans on the same DEXA scanner. Getting retested on a different manufacturer's scanner could give a false impression of bone loss (or gain).
Besides the Bone Scan: Other Tests for Osteoporosis

Are other tests needed besides a bone scan for osteoporosis? Certain medical conditions can cause thinning of the bones. These include:

* Kidney disease
* Hyperparathyroidism (overactive secretion of parathyroid hormone)
* Vitamin D deficiency
* Hyperthyroidism (overactive thyroid)
* Hyperthyroidism (overactive thyroid)
* Liver disease
* Intestinal disease

By taking your medical history and checking routine laboratory blood tests, your doctor can detect these and other causes for low bone density.

Since estrogen keeps bones strong, can getting your estrogen levels checked help? "Probably not," says Baker. Rarely, perimenopausal women with heavy periods might need hormone checks. But for the vast majority, "DEXA is the only test they need."

SOURCES:

National Osteoporosis Foundation web site: "Fast Facts."

Khan, A. CMAJ, 2002; vol 167: pp 1141-1145.

Cranney, A. Endocrine Reviews, 2002; vol 23: pp 496-507.

U.S. Preventive Services Task Force: "Osteoporosis: Prevention and Treatment."

National Osteoporosis Foundation web site: "Physician's Guide to Prevention and Treatment of Osteoporosis."

Committee statement, Journal of Clinical Densitometry, 2004; vol 7: pp 17-26.

Wainwright, S. Journal of Clinical Endocrinology and Metabolism, 2005; vol 90: pp 2787-2793.

National Osteoporosis Foundation web site: "BMD Testing: What the Numbers Mean."

Kolta, S. Osteoporosis International, 1999; vol 10: pp 14-19.

Conference of Radiation Control Program Directors' Task Force: "Technical White Paper: Bone Densitometry," October 2006.

Mary Rhee, MD, MS, endocrinologist and assistant professor of medicine, Emory University, Atlanta.

Felicia Cosman, MD, clinical director, National Osteoporosis Foundation.

Mary Zoe Baker, MD, endocrinologist and professor of medicine, University of Oklahoma Health Sciences Center.
Reviewed on July 30, 2007