James Underberg, MD: Hypercholesterolemia, Statin Intolerance

James Underbeg, MD, President Elect of the National Lipid Association, Clinical Assistant Professor of Medicine, NYU School of Medicine, NYU Center for the Prevention of Cardiovascular Disease: The important thing for patients to understand is that while there is certainly a lot of information out there about potential side-effects of statins, that has to be countered by the benefits. And in general statins are safe and effective and what's even more important is that in patients who have atherosclerotic cardiovascular disease those who can't take statins actually have a higher risk of having heart attack and cardiovascular events going forward.

That's very important information and it's just as important information to convey to a patient as are the potential risks of the medication that they're taking. So I think if you're going to impart the risk of a therapy you also have to make sure people understand the risk of not taking the therapy, because both are important in a patient's understanding and making a decision in their line about how they're going to do with that medication and certainly there are people who may have some mild side effects on these drugs, and their ability to continue them despite maybe a little bit of discomfort because they understand the potential benefits and they potentially outweigh discontinuation of the medicine.

So it's a complex conversation one has to have when someone starts on these medications, but I think the more engaged the patient is, and the more of a team that you create between you and the patient in deciding why you're going to use a particular drug like a statin, I think helps to ensure long-term adherence to that particular therapeutic option.

We're very lucky in the fields of cholesterol management we have a lot of options, and we're actually in the field where new options continue to be developed, at actually a remarkably rapid pace. So for those of us to do it we have a lot of tools in our armamentarium so to speak, but again, safe, effective, and inexpensive are the things that we always like to think of.

Those are my three kind of tech parts of the pedestal with the patient management. And so where do we start? We start with statins that's because statins are safe, perfective, and they're inexpensive. Too that often we now consider attending srebp especially when the LDL cholesterol level is very high. The srebp is not as potent as drugs like PCSK9 inhibitors so when the LDL cholesterol is lower, PCSK9 inhibitors which give you a greater reduction in LDL cholesterol, will probably result in a greater what we call net benefit to the patient, which is not only LDL lowering but potential reduction in cardiovascular risk, which is the key.

But they're more expensive right now, and so incremental therapy with newer agents is often not only a risk benefit analysis but a cost benefit analysis, and individual practitioners often not making that decision but systems and payers are. So we as practitioners have to adhere to what makes sense from a medical perspective but we have to do that within the context of the overall system wide perspective, which often does involve cost decisions .Some of those are under our control and some of them are not, but ultimately as newer agents get in and on and we have alternative therapies and so the decisions are not as linear as one would think and often at many decision points going forward we may have several options and an option for patient one may be different from patient two or patient three and it may be driven by the way the drug works, the side effects of the drug, or potential coverage. And so while there are issues with regard to new drugs and cost, that also creates a myriad of options that gives us some alternatives in the management of these patients.