Help understanding my lipid profile and statin choices?

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bladedmind
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Re: Help understanding my lipid profile and statin choices?

Postby bladedmind » Mon Mar 18, 2019 10:43 pm

I am grateful to all who spent some of their precious time sharing information and sympathy with me. I’ve been indecisive avoiding the lipids issue for several years and your comments have moved me to action.

My cardiologist’s advice is premised on my last blood test in June 2018. It occurred to me that a prescription for something that is so important to heart and brain health should not be based on data 9 months old - and only on the simplest type of panel. Before I act I want fresh data. I paid for my own blood test taken Saturday that includes particle size and insulin resistance. I ordered a used Cholestec from Ebay cheap (thanks to info gleaned from the board and private messaging help). And I will suggest to the physician that because of the cognitive risk I should have a full lipid profile and be tested more than once a year. The rosuvastatin is at lowest dose (5 mg) every other day and I might do it if I can monitor changes with objective data rather than waiting blindly to see whether I lose my memory again. My TG/HDL ratio is 10, when > 3 is a sign of much greater heart risk; that can’t be ignored.

Julie G, I admire you for your service to the APOE4 community and for your wide knowledge of AD. Thanks for the detailed ideas. My earlier loss of memory was caused by the lowest dose of pravastatin every other day. I was surprised myself. I might have erroneously attributed causation, but my memory cleared up in the weeks following cessation. As for lifestyle remedies, I’ve been unable to do more than 3 bouts of mild exercise a week because of post-exertional malaise since 2011 (it seems that over the last two months I’ve beat that back with an unorthodox treatment). But my lipids were the same as now back in 2008-2010 when I was lifting weights three times a week and running twice.

I’ve been following the perfect-health-diet for about five years, no grains, no legumes, etc.; more closely in the last two years. Your words prompted me to restudy keto and PHD diets. On PHD I can cut down carbs some and increase fat some, and also add plentiful nitric oxide greens (the greens you named I actually like but have not bothered to eat, not understanding their relevance). I don’t do well on full keto. However, I can get more aggressive about intermittent fasting, which is what Jaminet recommends. I’m now in the third day of a DIY fasting-mimicking diet, will repeat monthly for a few months; and will also work over the next two months to consistently extend my overnight fast from 12 to 16 hours. That would have good blood and brain consequences. Good to be pushed on Hb1aC!

I am long and strong on anti-inflammatories - fish oil, magnesium, CoQ10 (lately ubiquinol) for 20 years; metformin for 15; curcumin for 10; pomeguard, pterostilbene, EMIQ Quercetin, NAG, MSM, pine bark and grape seed extracts, ALA, NAC or glutathione, and others off and on.

Judy H, the knowledge shared on this board will allow us to guide our physicians to make better diagnoses and prescriptions.

NewRon, I saw a study showing increased risk of T2D from statins. But what the heck, I’ve already got T2D.

Fiver, there is no lipid clinic in my health system. My current cardiologist, who was assigned to me because recently hired, is beloved in patient ratings, so I will push her on questions first, gently asking whether there is a lipid specialist. We can correspond by system email.

Cflegal, I came across "The Role of Statins in Both Cognitive Impairment and Protection Against Dementia: a Tale of Two Mechanisms" as well. And also came across studies with evidence both ways. The truth is probably conditional - that statins help cognition in certain types of people, and hurts other types of people, but we don’t yet know the conditions.

Mike, I too recall seeing that study about a benefit only to a subgroup. I think statin advocates would respond that, regardless, statins are shown to extend longevity (probably because of their anti-inflammatory effect?). In reading study claims, I learned, it’s important to distinguish relative reduction of risk from absolute reduction of risk. If statins reduce risk from 2% to 1% adversity or death that’s a 50% relative reduction of risk but a 1% absolute reduction of risk.

SoCalGuy, I was teaching myself the various lipid components and studying the cholesterol medications and came to understand that my TC and my LDL are pretty good, but HDL and TG are not. As you pointed out, fibrates are good at raising HDL and lowering TG, and I will bring that up with the doc. And thanks or the reference, I will start speedwatching Dayspring tonight,

I will report back a few times in the next 6 months, and let you know what worked for me and what not.

The APOE4 board is helping a lot of people to enjoy better health.

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Re: Help understanding my lipid profile and statin choices?

Postby slacker » Tue Mar 19, 2019 5:23 am

bladedmind wrote:
SoCalGuy, I was teaching myself the various lipid components and studying the cholesterol medications and came to understand that my TC and my LDL are pretty good, but HDL and TG are not. As you pointed out, fibrates are good at raising HDL and lowering TG, and I will bring that up with the doc. And thanks or the reference, I will start speedwatching Dayspring tonight,

I will report back a few times in the next 6 months, and let you know what worked for me and what not.



I don't think that there are any studies that show that fibrates reduce the risk of coronary artery disease, despite improvement in lipid markers. And of course we are most interested in outcomes, not "surrogate" results of blood tests.

I have not listened to the Dayspring-palooza with Peter Attia. The show notes, which give more explanation, references, diagrams, etc, are no longer available without membership. I think you can get away with $10/month, and can possible pay month to month without a long term commitment. It may be difficult to follow the podcasts alone without this additional information. You can still access for free a 9 part article on cholesterol written by Attia, most likely inspired by Dayspring.

Yes, please let us know how you are doing!
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Re: Help understanding my lipid profile and statin choices?

Postby donbob » Tue Mar 19, 2019 6:44 am

I have been blessed with a wonderful doctor that follows me at the Veterans Hospital via annual physical exams. She has been very successful in moving me toward better lifestyle choices. I listen to her advice carefully and implement her suggestions. At the last two annuals, she suggested statins due to an algorithm that is driven by my age (71). 15% chance of a cardiac event in the next ten years. Not convinced, I decided to have a coronary artery calcification (CAC) scan.

My score was 19. When asked, she said she couldn’t provide a 10 year risk estimate using CAC results. I also have regular annual physicals with our family doctor. He ran my CAC score and estimated less than 3% risk of a cardiac event in the next ten years. He doesn’t think I need to follow up with another scan for five years, considering my lifestyle and dedication to glycemic control. He didn’t suggest statins.

Considering your parents life journey, perhaps get a CAC scan to see where you actually stand. That may inform your decision with regard to statin and other choices. Best wishes and may you find peace and happiness. Good luck.
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Re: Help understanding my lipid profile and statin choices?

Postby SoCalGuy » Tue Mar 19, 2019 8:54 am

bladedmind wrote:SoCalGuy, I was teaching myself the various lipid components and studying the cholesterol medications and came to understand that my TC and my LDL are pretty good, but HDL and TG are not. As you pointed out, fibrates are good at raising HDL and lowering TG, and I will bring that up with the doc. And thanks or the reference, I will start speedwatching Dayspring tonight,

I will report back a few times in the next 6 months, and let you know what worked for me and what not.

The APOE4 board is helping a lot of people to enjoy better health.


I think it's a great idea to get a more in depth lipid panel like NMR. If you can test Apo B that would be a great piece of data to have. I also do CAC scores and those are great to tell you where you are right now in terms of calcification. If you have none or very little it may give you the confidence to wait a little longer to get more data to assess your risk factors.

With T2D you may also want to research Ezitamibe. It is used to deal with fatty liver disease which may be part of the diabetes. I see you are on Metformin which is obviously used for T2D. The use of Ezitamibe for fatty liver disease is covered in the podcast as well. The episode that is going to be most relevant to you is episode 4.

Good luck!

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Re: Help understanding my lipid profile and statin choices?

Postby mike » Tue Mar 19, 2019 12:15 pm

donbob wrote:Not convinced, I decided to have a coronary artery calcification (CAC) scan.

My score was 19. When asked, she said she couldn’t provide a 10 year risk estimate using CAC results. I also have regular annual physicals with our family doctor. He ran my CAC score and estimated less than 3% risk of a cardiac event in the next ten years. He doesn’t think I need to follow up with another scan for five years, considering my lifestyle and dedication to glycemic control. He didn’t suggest statins.

Considering your parents life journey, perhaps get a CAC scan to see where you actually stand. That may inform your decision with regard to statin and other choices. Best wishes and may you find peace and happiness. Good luck.

My cardiologist also wanted me to do statins, and had me do a stress test, etc. All came out fine. Still wanted me to do statins. Said I should do the CAC, even though not covered by my insurance (but was not expensive) and I had a 2. He still wanted me to do statins. I asked about the Meta analysis, and he said this had all been decided years ago, and he didn't need to re-look... I asked him about coq10, and he said it was great for the heart. I asked him why he didn't suggest/prescribe it to me, and he just shrugged. This drug is so hyped by everyone because of the profits involved, makes me wary.
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Re: Help understanding my lipid profile and statin choices?

Postby bladedmind » Wed Mar 20, 2019 10:28 pm

My new NMR lipid test results are bad. Here’s my tentative plan. I’ll start the rosuvastatin at 5mg every other day and monitor basic levels at home, watching for excessively lowered cholesterol. Also will tune lifestyle. Will ask the cardiologist or otherwise measure desmosterol as marker of cognitive damage. If low-dose rosuvastatin is insufficient, per Dayspring, I’ll ask to add ezetimibe.

I have better data now than the simple panels from my health system.

I retrieved a big health panel done by my outside integrative physician in December 2014. It’s where I learned my APOE 4/4 status. My LDL-P then was borderline at 1577 (OK per Dayspring?), LDL-C OK at 99, CRP was 1.2. The panel also measured desmosterol - I had an optimal level - this point will become relevant below.

New Lipid Profile. I ordered the cheapest NMR profile from Walkinlab, just got results. Which are bad. Attia and Dayspring say that LDL-P is the essential measure. Or Apo B, not measured in this test.

    TC is 243, high for me (10-year average 186)
    HDL-C is 38 (10-year average 31)
    LDL-P is high at 2280 (very high risk) and LDL-C is high at 162
    TG is 213 high (10 year average 299)

    Particles
    HDL-P, low at 28.9
    Small LDL-P, high at 1232
    LDL Size 20.5, lower risk

    Insulin resistance at 47th percentile
Attia and Dayspring on cognition. I read Attia’s old blog series on cholesterol, and sampled the Attia-Dayspring podcast looking for measurement and treatment information. I also read the Dayspring thread here, and found Dayspring’s Lipid Treatment Algorithm pdf, posted by Stavia. I’m just beginning to understand some of this (and I know there are rival views), but some of you been at this since 2014.

Attia and Dayspring - all statin package inserts warn of cognitive impairment, and clearly a few patients do suffer it: don’t exaggerate it but don’t deny it. Despite one study, Dayspring doubts claim that statins lower dementia. Interesting sidelight elsewhere in the discussion: Dayspring earlier in life couldn’t tolerate statin or ezetimibe himself and recently has lost weight and improved lipids with low-carb diet and intermittent fasting.

The worry is about statin reducing cholesterol in the brain. Attia - aim for lowering LDL-P to a target level, but do not aim for zero. Dayspring - rosuvastatin 5 milligrams is all a lot of people need. You don’t need 40. The discussion is more entertaining, but can be efficiently summarized by this quote I found in Apoe4Info pulled from Dayspring’s Lecturepad course (now defunct):

Next I will venture into hypothesis territory. Low desmosterol is emerging as a marker of Alzheimer's disease (J. Lipid Res. 2012. 53: 567–576, Journal of Alzheimer’s Disease 2013;33:881–888)and it is well known that statins in a minority of patients have been associated with CNS issues included cognitive disturbances. My hypothesis is that over suppressing cholesterol synthesis in the brain with statin therapy, which would be indicated by reduced desmosterol or lathosterol, may not be desirable and perhaps is in-part causal of statin-induced cognitive issues. So when I see a statin reducing desmosterol too much, I back off on the statin dose. If needed to maintain atherogenic lipoprotein goal I use other apoB-lowering meds in combination with a lower dose of the statin. Obviously if hyperabsorption of cholesterol is present, ezetimibe would be the perfect add-on apoB-lowering therapy. It is well established that lower dose statin plus ezetimibe is as or even more efficacious in LDL lowering that high dose statin monotherapy.

Desmosterol as Alzeimer’s biomarker (noted several times on Apoe4Info):

    https://www.ncbi.nlm.nih.gov/pubmed/22203775
    J Lipid Res. 2012 Mar;53(3):567-76. doi: 10.1194/jlr.M022376. Epub 2011 Dec 27.
    Identification of a new plasma biomarker of Alzheimer's disease using metabolomics technology.

    Also, Wisniewski et al.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3557460/
Draft action plan. Advice and critique welcome!

    Lifestyle: carb down some, fat up some; regulate fructose intake by measurement; fasting-mimicking diet monthly for first three 3 months; expand overnight fast from 12 to 16 hours; add nitric oxide greens.
    Somehow measure desmosterol baseline.
    Take rosuvastatin 5 mg EOD.
    Monitor my lipids at home with Cholestech every few weeks.
    If I feel cognitive decline, or if my TC or LDL go below target level, I will contact the cardiologist and request action.
    If we need to increase medication, we’ll add ezetimibe.
    The system will do a NMR lipid test at times when it is necessary to measure my progress.

I’m not sure of the best way to persuade the rule-constrained cardiologist to do what I want. The 2014 Statin Cognitive Safety Taskforce (which is rather grudging about admitting a safety problem) recommends that
Subjective patient complaints of cognitive symptoms should not be dismissed nor minimized. Indeed, if a patient who is taking a statin reports cognitive difficulties, which he or she perceives as related to statin use, then the clinician should evaluate this complaint in detail…. it is reasonable for the drug to be discontinued for 1 to 2 months before considering a rechallenge. The patient should be reassessed frequently (eg, every 1-2 months) with the same cognitive screening measure that was used to document the affected cognitive domain(s) until he or she no longer reports cognitive difficulties before a rechallenge.

https://www.lipidjournal.com/article/S1933-2874(14)00075-0/fulltext

GIven that I made my APOE 4/4 status known, that no tests were done for me when my memory vanished with pravastatin, that a statin was represcribed without any plan for pre and post cognitive investigations, that my livelihood would be threatened by even temporary cognitive damage, it seems to me that she should be flexible and vigilant about monitoring statin effects, and that desmosterol is an easier and more objective way to do that.

I have a feeling I will be denied desmosterol testing. Anyone know an online lab that does a sterol panel? Nothing on requestatest, walkinlab, labtestsonline, directlabs, looking for “sterol” or “desmosterol.” Learned from board of Boston Labs, but that’s a Rx plus iced shipping.

Attia’s boutique practice has a satellite in San Diego, Gundry is in Palm Springs. Any other lipid wizards in between San Diego and San Francisco?

Thanks for your help! I’ve learned and made a lot of progress.

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Re: Help understanding my lipid profile and statin choices?

Postby Stavia » Thu Mar 21, 2019 8:54 am

Hi Bladedmind. I have my sympathy for your dilemma.
A couple of thoughts: Rosuvastatin tablets can be cut easily. It doesnt matter hugely if the halves are not exactly equal. An option could be to start on 2.5mg EOD.( This is not specific medical advice for you, just a thought). I had awful brain fog when I was erroneously started on 20mg atorvastatin a few years ago ( it started about 10 days in; and resolved 2 weeks after stopping). If I needed a statin now, I would be starting with 2.5mg rosuvastatin EOD and seeing how I felt and how my risk markers responded
We truly do not have evidence as to what the lowest effective dose of a statin is.

My second thought is that your real CVD is likely much higher than the 2% you were looking at when you accurately described the difference between RRR and ARR. Your situation is one where I would definitely seriously consider a statin for my patients. There is likely significant soft plaque that would not show on CT.

Boston labs are the only one I know of that do absorption/production markers. But the response to a statin/ezetimibe will tell you as well. I did it some years ago: as a 4/4 I was a hyperabsorber, but a hyperproducer as well. So my LDL plummeted on the statin.

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Re: Help understanding my lipid profile and statin choices?

Postby bladedmind » Thu Mar 21, 2019 3:04 pm

Thanks very much for your informed insights, Stavia.

I’m interested in the sterol panel to monitor changes in desmosterol as a cognition biomarker. I don’t understand the cholesterol absorption issues yet, but plan to self-teach it from the Attia-Dayspring material next week. I found more labs offering sterols analysis, but not online walk-in: https://www.mayocliniclabs.com/test-cat ... view/82079 Also, maybe https://www.kennedykrieger.org/patient- ... al-testing in Baltimore.

The 2% risk was just to illustrate RRR & ARR. My 10-year risk is 47% by ACC and 42% by AHA. I can’t ignore this. Just wish there was caregiver awareness and vigilance about my cognitive risks.

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Re: RE: Re: Help understanding my lipid profile and statin choices?

Postby Stavia » Fri Mar 22, 2019 1:42 pm

bladedmind wrote:Thanks very much for your informed insights, Stavia.

I’m interested in the sterol panel to monitor changes in desmosterol as a cognition biomarker. I don’t understand the cholesterol absorption issues yet, but plan to self-teach it from the Attia-Dayspring material next week. I found more labs offering sterols analysis, but not online walk-in: https://www.mayocliniclabs.com/test-cat ... view/82079 Also, maybe https://www.kennedykrieger.org/patient- ... al-testing in Baltimore.

The 2% risk was just to illustrate RRR & ARR. My 10-year risk is 47% by ACC and 42% by AHA. I can’t ignore this. Just wish there was caregiver awareness and vigilance about my cognitive risks.
Aha I understand. My Boston Labs test was very expensive, about $500 US. In retrospect a waste of money, my coronary calcium score a few years later proved to be zero.
I guess you would need several, and its not a validated marker of cognition.
Cheaper and more validated to do serial cognitive testing?
But I do understand your concerns - kinda between a rock and a hard place huh. Tricky to find the safest path.

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Re: Help understanding my lipid profile and statin choices?

Postby SoCalGuy » Sat Mar 23, 2019 9:31 am

bladedmind wrote:New Lipid Profile. I ordered the cheapest NMR profile from Walkinlab, just got results. Which are bad. Attia and Dayspring say that LDL-P is the essential measure. Or Apo B, not measured in this test.

    TC is 243, high for me (10-year average 186)
    HDL-C is 38 (10-year average 31)
    LDL-P is high at 2280 (very high risk) and LDL-C is high at 162
    TG is 213 high (10 year average 299)

    Particles
    HDL-P, low at 28.9
    Small LDL-P, high at 1232
    LDL Size 20.5, lower risk

    Insulin resistance at 47th percentile

Thanks for your help! I’ve learned and made a lot of progress.


My LDL-P was never as high as yours but I found mine troubling as well. By taking 5mg rosuvastatin I've cut it down to to the mid 700s so I feel pretty good about that and agree with Dayspring's suggestion to take a "baby" aspirin equivalent, ie low dose statin so long as you do not experience any cognitive decline in order to get LDL-P or Apo B under control. I also recall hearing in the Attia podcast that some statins like atorvastatin and simvastatin can get into the brain which should be a big concern for anyone with an APOE 4 allele or two.

I asked my doc to measure desmosterol but she indicated she'd have no idea how to read the results which wasn't encouraging. I need to check out the Attia list of docs in my area and find one. If I do I will let you know since I think you are in the SoCal area as well. At least she agreed that 5mg of rosuvastatin was sufficient now that my LDL-C is below 70.

Finally, I have started running consistently once again. I typically run 30-45 minutes per day. The one clear benefit thus far has been a boost to my vitamin d levels, which have gone up 50% since I started running again. Not cholesterol or heart related, but higher vitamin d levels do seem to be correlated with better health.


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