Case 132 is fascinating, Gene - thanks for sharing. I especially enjoyed the discussion of how high intestinal cholesterol absorption downregulates hepatic LDL receptors (thereby slowing LDL particle clearance) as well as hepatic cholesterol synthesis (thereby reducing the effectiveness of statin therapy). I also understand now why ezetimibe is typically combined with a statin - ezetimibe reduces intestinal absorption, which upregulates hepatic cholesterol synthesis, which then requires a statin to downregulate.
I appreciate the cautionary note regarding Vytorin, the ezetimibe / statin combo pill. Dr. Dayspring's buttons, levers, and dials approach to managing lipids is attractive, but using potent pharmaceuticals to control fundamental metabolic processes also carries risk. As someone who doesn't fit any of the four scenarios in Dr. Dayspring's lipid treatment algorithm, I think I'll continue to content myself with using foods and food-like substances (e.g. sardines, nuts, niacin, psyllium husk, amla, cod liver oil, etc.) to optimize health. I continue to believe
that there is some epidemiological uncertainty regarding the overall
health benefits of using drugs to change lipid metabolism in the absence of existing heart disease or rare genetic defects like familial hypercholesterolemia.