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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

What Your Doctor Is Reading What Your Doctor Is Reading

Update From the Medical Journals: November 2013

December 02, 2013

By Mary Pickett M.D.

Harvard Medical School

What's the latest news in the medical journals this month? Find out what your doctor is reading.

New Cholesterol Guidelines Say More People Should Take Statins, or Increase Their Dose

Doctors and the American public are considering new cholesterol guidelines that were released on November 12 in the journal Circulation. The advice is from the American Heart Association (AHA) and American College of Cardiology (ACC). These guidelines  update and replace the 2004 recommendations from the National Heart, Lung, and Blood Institute and the National Cholesterol Education Project (NCEP). The experts who wrote the guidelines reviewed previously published data on the benefits and harms of cholesterol treatment.

Many doctors are unsure whether they completely agree with the guidelines.  The guidelines recommend greatly expanding the number of people who take statins, cholesterol medicines that are known to reduce heart attack risk. 

Previously, doctors used statins to lower LDL to a target number. But the new guidelines change that. Doctors should start statin treatment if a person is in any of these 4 groups:

    1. People with a history of  atherosclerosis (coronary artery disease, stroke or other artery disease)
    2. People between 40-75 years of age who have diabetes
    3. People with very high LDL cholesterol (at or above 190 mg/dL)
    4. People who have a 10-year risk of heart attack OR stroke that is more than 7.5% (exceptions would be people whose LDL is extremely low (less than 70 mg/dL) without a statin

For the last group, the AHA and ACC have developed a risk calculator that takes into consideration your age, race, smoking history, cholesterol levels and whether or not you have diabetes or high blood pressure. 

The new guidelines also recommend that most people take a high dose of a statin drug, rather than starting low and adjusting the dose based on cholesterol levels. High-dose treatment is appropriate for most people on statins who are younger than age 75. Exceptions would be people who have liver, kidney or muscle disease, people who have experienced side effects from statins, and people who qualify for treatment but have a relatively small calculated risk for heart attack and stroke. Examples of high doses are atorvastatin (Lipitor) 40 to 80 milligrams, or rosuvastatin (Crestor) 20 to 40 milligrams. 

You should have your cholesterol tested every 4 to 6 years after age 40, so that your risk can be periodically re-calculated. If you start taking a statin drug, yearly cholesterol tests can help your doctor to verify that you are having the expected benefit from your statin drug, even though your dose won't depend so strongly on your specific cholesterol numbers.

These guidelines roughly double the number of American adults who might consider taking a statin. Is that too many people?

We have good evidence that statins help to prevent heart attack and stroke. But for lower-risk people, this guideline doesn't adequately take into account the costs of statins and some of their potential side effects. Experts who question the new guidelines are concerned that the risk calculator might overestimate heart and stroke risks. They also say that the guidelines recommend treating too many people who have only modest risk for cardiovascular disease. They say the benefits may be too small to be worthwhile. According to the experts' calculations, 140 people who have less than 10% risk of a heart attack over the next 5 years would need to take statins for 5 years to prevent 1 heart attack. This is not only an expensive proposition, but exposes many people to side effects. These can include muscle pain, fatigue at peak exercise, sexual performance side effects, a small increased risk for diabetes (especially in women), liver inflammation, cataracts and possibly memory problems. 

Lifestyle factors such as poor exercise, diet and smoking habits account for the majority of your risk for heart and artery disease. This guideline and previous guidelines agree that good health habits are the best way to prevent heart disease. Talk to your health care provider about these guidelines and how they might apply to you.

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More News In Brief

  • Gabapentin May Help Alcoholics to Get Sober. The commonly prescribed medicine gabapentin (Neurontin) may help people with alcohol dependence get sober, says a new study. This medicine has been used for a variety of purposes, including seizure prevention and pain control. This new use is an exciting possibility. The study had 150 patients enrolled. It was supported by the National Institutes of Health (NIH). It was published November 4 by JAMA Internal Medicine. The participants were recruited because they were heavy drinkers who wanted to stop drinking. They were divided into three groups. One group got 1,800 milligrams of gabapentin per day, split into several doses. A second group got half of this dose. A third group received a placebo.

    These participants took their medicine for 12 weeks and made efforts to limit their drinking. The results showed that people taking gabapentin at the higher dose were twice as likely to successfully avoid heavy drinking and 4 times as likely to avoid alcohol completely, compared with people who were treated with placebo. Those who got gabapentin also seemed to sleep better, to have improved mood, and to have fewer alcohol cravings. The group that took low-dose gabapentin had similar benefits, but the benefits were not as large.

    This study was small, so it is premature to make a sweeping recommendation that gabapentin be prescribed to all alcoholics who are working to cut back or stop drinking. But it seems like a low-risk way to possibly improve your chances of success. This medicine is well tolerated by most people who use it. We can look forward to more research on this possible new use for gabapentin.

  • More Kids Are Diagnosed with ADHD. The U.S. Centers for Disease Control and Prevention (CDC) reported a rapid rise in the number of children who are being diagnosed with attention-deficit hyperactivity disorder (ADHD). The CDC also reported a rise in the number of kids being treated with ADHD medicines, like methylphenidate (Ritalin). Researchers at the CDC compared data from 2003 to data from 2011. During this time, the rate of ADHD diagnosis increased by 42%. In 2011, 11% of children and adolescents aged 4 to 17 had an ADHD diagnosis. This is an all-time high. Currently, 69% of kids with ADHD take medication. Some of the increase in diagnosis comes from a heightened awareness of the disease. The updated statistics were published November 19 in the Journal of the American Academy of Child Adolescent Psychiatry. 
  • Pregnant Women: Beware of Phthalates. A November 18 study in JAMA Pediatrics reports that the odds of preterm delivery may be higher for pregnant women who are exposed to phthalates. These chemicals are present in a variety of products, especially plastics, personal care products (including baby lotions, shampoos, wipes, creams and powders), toys, cleaning products, plastic containers, paints, air fresheners and plastic wrap. The indication that phthalates may lead to premature birth comes from indirect evidence. Researchers compared urine samples of 130 women who had a preterm birth and 352 women who did not have premature birth. Phthalates byproducts were found in higher levels in the urine, on average, in the group with preterm birth. More study will be needed to further understand whether phthalate exposure can lead to preterm delivery. In the meantime, it is prudent to avoid phthalates, particularly if you are pregnant. To reduce phthalate exposure limit your use of perfumes and cosmetics. Use washcloths instead of packaged wipes. Store or microwave food in glass or ceramic containers. Clean with natural products (such as vinegar, lemon juice, and baking soda), and use waxed paper or paper towels in place of plastic wrap when you are microwaving foods. 
  • Fibromyalgia May Come from Changes in the Brain. The journal Arthritis & Rheumatism published a study November 5 that may add to our understanding of fibromyalgia. People who have fibromyalgia have joint and muscle pain without having inflammation or injury. In a small study, researchers compared brain magnetic resonance imaging (MRI) pictures for 31 patients with fibromyalgia and 14 healthy controls. The type of MRI used was a "functional MRI." This type shows the level of activity in different brain areas. Brain areas involved in pain anticipation and pain relief seemed to behave differently in patients with fibromyalgia compared to people without the condition. A brain region called the ventral tegmental area was underactive in fibromyalgia patients. This study strengthens the idea that fibromyalgia may be a problem with how the brain regulates the experience of pain. Because fibromyalgia is a problem that we do not understand well, any new insights into this problem are helpful. This study is likely to inform future research about fibromyalgia.

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Mary Pickett, M.D., is an associate professor at Oregon Health Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.

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