Thursday, October 14, 2010

Success!!! got my patient's LDL to 50mg/dl

First question.......What's the benefit of doing the above? We all know that lower the cholesterol..lower the cardiovascular risk. Latest evidence supports lowering it to < 70 mg/dl for the high risk patients. there a downside to overdoing this? Yes there is... at least theoretically ..for now.
The normal LDL level is 40 - 70 mg/dl. Cholesterol (mainly LDL particles) play a major role..and are the corner stone for synthesis of many steroid hormones including cortisol, tetosterone, androstenidione, Vitamin D etc. So by looking at this...obviously driving LDL to a much lower level can affect these important physiological processes.
There were a few studies done to see if reduction in LDL with statins affect endogenous steroidogenesis. In a cross sectional study of 350 type 2 diabetic patients on a statin (Diabetes care 2009) showed a significant reduction in total testosterone level with atorvastatin compared with no treatment. But the free bio available testosterone levels were normal. A pharmacology study from Holland shows the same above possibility with Statins.(British J of Clin Pharmacology )

A subgroup analysis of reproductive age group women from WISE trial showed no significant decrease in levels of estrogen or progesterone in pts with LDL < 70 Vs pts with LDL >70. (AJM 2002).
An earlier study from 1994 showed no decrease in levels of adrenal and gonadal steroids in patients with a low LDL on a statin. Most of the above studies...didnt drive down the LDL levels to < 70mg/dl.
A recent study published in 2009 comparing gonadal hormones in pts with LDL <70 with LDL < pts on a statin..showed no significant difference in the sex hormone levels..over a period of 12 weeks. This may be a short duration to assess a reasonable outcome.

On the whole...driving the LDL levels to < 70 may have little or no negative effect on sex &/or adrenal hormone levels. But this possibility can be considered if a pt..with a LDL of <70 complains of decreasing libido.(these pts may also be on Spironolactone..which can make this worse).
Statins have shown some benefit in treating prostate cancer( again..may be due to their effect on lowering levels of testosterone!). Another theoretical concern with excessive lowering of cholesterol will be the possibility of a lack of adrenergic response needed during stress (especially in sepsis, ICU admissions etc) due to low cortisol production. Whether this is true remains to be answered !!