Peter Hibberd, M.D., is a doctor whose advice is based on more than 28 years of hospital outpatient and inpatient experience. He is an experienced emergency medicine physician, surgeon, and consultant. Dr. Hibberd is certified by the American Board of Emergency Medicine. He is also a fellow and active member of the American Academy of Family Physicians, an active member of the American College of Emergency Physicians, and a member and fellow of the American Academy of Emergency Medicine. Dr. Hibberd has earned numerous national and international professional certifications, memberships, and awards.

What Can I Do to Lower My LDL Other Than More Drugs?

Friday, 11 June 2010 04:07 PM

Question: I am 42 yrs old, and in great shape — I eat right etc. etc. My total cholesterol has always been between 210 and 245; my triglycerides are 125; my HDL 42. But my LDL spiked from 145 to 180. It was never higher than 145 before.
I think I may have had an adverse reaction to fish oil pills. Can that be possible? I was taking 2,400-3,600 milligrams a day along with flaxseed in my oatmeal. One doctor wants to put me on a statin, another doctor doesn’t feel comfortable putting me on statins. She suggested non-flush niacin and more testing after the holidays such as an cardiac cat scan. I took this test in 2001 and got a perfect score which meant I didn’t have any blockage. I don’t want to take these drugs.
I am currently taking red yeast rice (2,400 milligrams a day) along with 10 milligrams of policosanol, 710 milligrams of plant sterols, non flush niacin (1,500 milligrams three times day). Is there anything else I can do?

Dr. Hibberd's Answer:
Wow. You are a model patient. You are probably doing better than you think. Your impression of the effect the high dosing of non-dietary fish oil supplementation may indeed be correct. You may be overdoing this and should moderate your intake to 1,200 milligrams daily since you already consume significant fish intake in your diet. More is not always better here.
Intake of omega-3 fatty acids (in fish oil known as DHA and EPA) can be used to titrate for triglyceride control while monitoring for LDL change. Effective doses can range from 3 to 5 grams per day in the treatment of marked hypertriglyceridemia (triglycerides over 750 mg/dl). One caution is important here. These higher doses can only be obtained consistently by supplementation. Patients taking more than 3 grams of EPA and DHA (omega-3 fatty acids) should do so only under a physician's care because the FDA has noted an intake in excess of this level could result in excessive bleeding in some individuals.
Here are my other thoughts:
•I'm not sure what to say about the plant sterols, you are on your own there, and I would be interested in your reasons for using them.
•Your dosing of niacin has already been maxed out and further benefits are unlikely. Many patients supplement themselves with psillium or use 2 tbsp Metamucil twice daily to achieve up to 10 percent improvement in LDL.
•The flaxseed in your oatmeal is probably unnecessary and may indeed be upsetting the balance of your supplemental routine with an overabundance of omega-6.
•In my opinion, policosanol has little data to warrant taking it as a supplement.
•Stop your red yeast rice. In 1997, a red yeast rice product called Cholestin was marketed in the U.S. as a cholesterol-lowering supplement. It was found to contain small amounts of Lovastatin and other statins formed in the fermenting process. It was removed from the market by judicial order since it contained an unapproved drug (monocolin K: lovastatin). Cholestin later returned to the market containing policosanol with its unclear efficacy and conflicting evidence. So much for the safety of some supplements!
•Increase your dietary soluble fiber to 40 grams per day, then review your LDL readings in two to four weeks for observed effect.
The cardiac CTT scan (which shows coronary calcifications and is reflected as a score used for establishing risk of established coronary artery disease) is probably overkill given your negative prior scan and the information provided is not likely to sway your therapy. Note this study is immensely popular in the U.K. and Europe, but not as popular in the USA where some health insurers balk at its payment.
Recheck your lipid and LDL figures before committing yourself to statin treatment. You didn't mention the improvement that you saw with niacin treatment, so the decision to substitute or add the statin would be dependant upon the benefits seen on Niacin. I usually like to be cautious with combinations of statins and niacin.
I would not be adverse to a trial on statin for effect especially with your low HDL and rising LDL. If you do, consider adding CoQ10 50-100 milligrams daily to minimize the nuisance problems so often seen with statins. Be sure to check your chemistries and review your other risk factors for coronary artery disease with your doctor (diabetes, family history etc) and discuss your options with your favored consultant.
Both your doctors seem to have your benefits at heart, and they are simply approaching your treatment from slightly differing perspectives, both of which can be seen as correct by current standards. Always discuss supplement use with your doctor to avoid interactions and complications in therapy and treatment decisions.
Consider minimizing excessive supplement use when entering conventional treatment regimens to properly guage the effects of treatment as well as to minimize interactions that may not have been considered.

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Friday, 11 June 2010 04:07 PM
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