January 20, 2012 | 6:44 pm

How Frequently Should You Have Your Bone Density Checked?

Posted by Albert Fuchs, M.D.

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Breaking a bone is frequently a catastrophic injury for an older patient. A hip fracture or a vertebral fracture frequently leads to a permanent decrease in mobility which starts an inexorable decline in health and independence. For that reason, fracture prevention is a critical part of the care of older people.

Osteoporosis, which is severely decreased bone density, is a major risk factor for fractures, especially in women over 65. Osteoporosis is also treatable, and there is good evidence that treating osteoporosis with bisphosphonates (a family of medicines which includes Fosamax, Actonel, and Boniva) prevents fractures.

So we know that testing bone density is important in women over 65. But we don’t know how frequently we should be recommending the test. Medicare pays for the test every two years, and in the absence of scientific information about how frequently the test is valuable, that has become the accepted default.

This week’s New England Journal of Medicine published a study that helps shed some light on the question. Almost 5,000 women 67 years of age older who did not have osteoporosis at the beginning of the study were enrolled. The women had periodic bone density studies for up to 15 years. The goal of the study was to find the length of time between tests that would safely detect most cases of osteoporosis before a fracture occurred.

Not surprisingly the safe testing interval depends a lot on the initial bone density. For women with advanced osteopenia*, a testing interval of only 1 year was required to detect osteoporosis in time. For women with moderate osteopenia, retesting in 4 years was adequate. Women with mild osteopenia or normal bone density could wait 15 years before the next test. The intervals also varied with the age of the women, with younger women losing bone density more slowly than older women.

These findings should be validated in large studies before put to use. But if the general theme is right, women in their 60s with normal bone density can safely defer their next test for a decade.

Learn more:

Patients With Normal Bone Density Can Delay Retests, Study Suggests (NY Times)
Many Older Women May Not Need Frequent Bone Scans (Shots, NPR’s health blog)
How Often Should Women Be Screened for Osteoporosis? (Wall Street Journal health blog)
Bone-Density Testing Interval and Transition to Osteoporosis in Older Women (New England Journal of Medicine article)
Medications for Osteoporosis (my summary in 2008)

* Definition of various levels of bone density according to T score
Bone Density         T score
Normal               greater than -1
Mild osteopenia       between -1 and -1.5
Moderate osteopenia between -1.5 and -2
Advanced osteopenia between -2 and -2.5
Osteoporosis           less than -2.5

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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January 13, 2012 | 8:51 am

Why Losing Weight Is So Hard

Posted by Albert Fuchs, M.D.

I’ve written many times that losing weight is the second hardest thing I ask my patients to do. (Breaking an addiction like smoking or alcoholism is the hardest.) The frustrating thing is how little we know about how to lose weight successfully. But we are learning more all the time about why losing weight is so difficult.

Much about dieting and weight loss is poorly understood, but let’s first lay out some facts that are well established.

Weight loss and weight gain are caused by an imbalance between calories ingested and calories burned. That’s not controversial. If you eat fewer calories than you use in exercising, you will lose weight. If you eat more, you will gain. How many calories it takes to simply maintain one’s weight varies between individuals and the mechanisms behind that variation are still being explored, but for every person there is a number of ingested calories below which weight loss will happen. That means that if someone else is in control of what you eat (for example in a prison in a totalitarian country) and doesn’t provide you enough food, you will lose weight.

That makes it sound fairly simple, right? If you eat less, you lose weight. Since eating is a volitional behavior, overweight people should simply choose to eat less, and their failure to do so simply reflects poor judgment or weak willpower.

Wrong.

Permit me a brief digression about control systems. I think about them a lot because of my engineering background. Our body has many mechanisms that very tightly regulate certain biological parameters, like the sodium concentration in our blood, or the amount of light that is shining on our retinas. Many of these mechanisms are entirely out of our conscious control. For example, if we walk into a brighter environment our pupils automatically constrict, letting less light hit our retinas. That happens without our attention or knowledge.

The control of our breathing is a very interesting example. Our breathing is usually not under our conscious control. Our brain monitors the amount of carbon dioxide (CO2) in our blood from moment to moment. When the level of CO2 increases we take a breath, lowering the CO2 level. The cycle repeats continuously even in our sleep. Without our attention or intention the CO2 level in our blood is kept within a fairly narrow range. But anyone who plays a wind instrument or sings can tell you that breathing is also volitional. You can take a breath purposefully between sentences and blow through a horn exactly when you want to. So which is it? Is breathing voluntary or not?

The answer depends on the time scale. From second to second you can control your breathing. You can hold your breath for a few seconds or you can hyperventilate for a few seconds. But over minutes you will not be able to override the drive to keep your CO2 at a certain level. That is, if you try to hold your breath or slow down your breathing over minutes, your CO2 will slowly climb and your urge to breathe faster will eventually prove to be irresistible. Similarly if you try to hyperventilate over minutes, your CO2 will fall and your urge to slow your breathing will eventually overwhelm your conscious control. So breathing is voluntary over seconds but entirely involuntary over minutes or longer.

Are you getting a sense of how this may relate to control of weight?

Long ago researchers began suspecting that there were control mechanisms responsible for maintaining weight within some range. Just as there is an internal set point for our blood sodium concentration that the kidneys maintain, and a set point for our CO2 concentration maintained by our breathing, researchers argued that there must be an internal set point for our weight. A set point simply means a normal level of some measure that a control mechanism tries to achieve – the temperature that the thermostat is set to, for example.

I first discovered the idea of a possible weight set point in a fascinating paper by Seth Roberts, a psychologist. He cites much evidence that weight must be controlled by an internal set point. For instance, many people occasionally fast for a day. This results in a small weight loss. Without an internal set point for weight, that weight loss would be permanent or would fade very slowly. But weight loss after a fast usually disappears within a few days, suggesting that hunger is increased for the subsequent few days until the weight renormalizes.

The general idea is that the quantity of fat stores in our body is monitored by our brain (perhaps using hormones released by fat cells) and compared to some set point. Whenever our weight (or fat stores) falls below this set point various hormonal mechanisms increase hunger and decrease physical activity. Research is currently attempting to unfold the details of these mechanisms. The current understanding and consequences of this theory is explained in a illuminating article in the New York Times Magazine – The Fat Trap. If you’re trying to lose weight, I urge you to read it.

The article cites several studies including a study published in The New England Journal of Medicine in October. The study enrolled 50 overweight or obese adults and for 10 weeks put them on a very low calorie diet. They lost an average of 30 lb. Before the study and periodically for a year after, the levels of hormones thought to mediate hunger and satiety were measured. The subjects were also asked for their subjective levels of hunger and appetite.

The results showed that the hormones that cause hunger and weight gain increased after the weight loss and remained increased a full year later, even after most subjects had partially regained their lost weight. More sobering is the fact that the subjects’ self-reported sense of hunger rose after the weight loss and didn’t return to baseline levels throughout the one year study.

The authors state that the result

“supports the view that there is an elevated body-weight set point in obese persons and that efforts to reduce weight below this point are vigorously resisted… suggesting that the high rate of relapse among obese people who have lost weight has a strong physiological basis and is not simply the result of the voluntary resumption of old habits.”

For now, this isn’t a particularly helpful discovery, but it helps explain a lot. It explains, for example, why the myriad diets on the market all have approximately the same lousy long-term success rates. It also explains that eating, like breathing, and like refraining from scratching that patch of eczema, is a voluntary behavior only on short time scales. I can choose whether to have a snack now or not, but I can’t choose to fast for three days or to eat much less than my caloric needs for a month.

Overweight people have a “weight thermostat” that is turned up too high. We need researchers to to find a medical solution to reset this set point or to break one of the mechanisms that mediate hunger.

The best we have to offer overweight patients at this point is the advice to diet and exercise, though in the long term this seems to be effective only for a small minority of patients. For the morbidly obese, surgery for weight loss is an increasingly evidence-based option.

Perhaps the best advice we can learn from this is to at least encourage patients not to gain more weight. We now know that losing it will be much more difficult and that maintaining the current weight after weight gain and loss will be harder than never gaining in the first place.

Learn more:

The Fat Trap (New York Times Magazine)
Long-Term Persistence of Hormonal Adaptations to Weight Loss (New England Journal of Medicine article)
What Makes Food Fattening? A Pavlovian Theory of Weight Control (Seth Roberts, unpublished paper)
My previous posts on weight loss

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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January 6, 2012 | 4:54 pm

Home Exercises or Chiropractic Care Beat Medications for Neck Pain

Posted by Albert Fuchs, M.D.

Neck pain is a very common problem. Many of us have woken up with a painful neck and found that we couldn’t turn our head because of painful muscle spasm. Doctors use various treatments for neck pain. Pain medication, spinal manipulation by a chiropractor, and physical therapy for stretching exercises are all popular remedies, but there is very little scientific evidence to support any of them. I frequently used to prescribe anti-inflammatory pain medications as an initial treatment, but not anymore.

This issue of Annals of Internal Medicine published a study that sheds some light on the issue. Researchers recruited 272 patients suffering from neck pain for at least two weeks. They were randomized to three groups, each of which were assigned a different treatment for 12 weeks.

One group was prescribed medication by a physician. Medications included anti-inflammatory pain medicines (like ibuprofen or naproxen), acetaminophen (Tylenol), muscle relaxants, and even narcotics if the doctor thought they were indicated. The second group saw a chiropractor once or twice per week for spinal manipulation. The third group met twice with physical therapists who taught them to do home exercises. They were asked to continue the exercises for the 12 weeks of treatment.

All patients were followed for a year after the start of the study to periodically measure their pain and range of motion.

Surprisingly, both the home exercise group and the chiropractic spinal manipulation group did much better than the medication group. And there was not a significant difference in outcomes between the home exercise group and the chiropractor group.

So the next time you get a crick in your neck, check out the home exercises in the supplement to the Annals study. If you can’t figure them out yourself, get a physical therapist to teach them to you. Or see a chiropractor. And I’ll still prescribe pain medicine if pressed but first I’ll recommend the more effective treatments.

Learn more:

For Neck Pain, Chiropractic and Exercise Are Better Than Drugs (NY Times, Well column)
Neck Pain? Skip the Pills, Just Stretch Like a Chicken (Wall Street Journal, Health & Wellness)
Is Spinal Manipulation an Effective Treatment for Neck Pain? (Annals of Internal Medicine, Summaries for Patients)
Neck exercises (Annals of Internal Medicine, supplement)
Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain (Annals of Internal Medicine article)
Pain in the Neck: Many (Marginally Different) Treatment Choices (Annals of Internal Medicine editorial)

Tangential Miscellany

Five years ago, I had the inexplicable and probably misguided idea that what the world really needed was one more physician blogger. In the interim I’ve been delighted to build a readership of people who send me frequent ideas for stories and lots of feedback about my posts. This is my 300th post, and I wouldn’t keep doing it without the wonderful encouragement and praise from all of you. Thank you very much for reading.

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment

December 30, 2011 | 11:58 am

Do You Want to Read What I Write About You?

Posted by Albert Fuchs, M.D.

All patients have a right to a copy of their medical record. In practice that right is rarely exercised. It usually means submitting a request in writing, paying a fee for photocopying, and waiting weeks for someone to copy and mail the records. The development of electronic medical records has the potential to revolutionize patients’ access to their records, making it possible for patients to review their records securely whenever they want from any internet-connected computer.

But would patients want that? Would it improve their care? Would it help or hinder their doctors’ work?

An interesting study aims to answer these questions. The pilot program, called OpenNotes, approached primary care physicians working for three health care systems in Boston, Seattle, and rural Pennsylvania. These physicians were already working in organizations that used electronic health records. Some of these records already had features that allowed patients access over the internet to their medication list or to their laboratory test results, but none offered patients a chance to review doctor notes. The study proposed to give patients access over the internet to their physician notes for one year. All the physicians in the three locations were invited to participate but had the option of declining. Only the patients of participating physicians were given access to their notes.

We won’t have the actual results from the OpenNotes project for another year. This issue of Annals of Internal Medicine published the results of questionnaires completed by the physicians and the patients prior to the study. The questionnaires asked the physicians and patients about their expectations of how patient access to notes will impact care, and about the potential benefits and harms of this access.

The difference in the answers between physicians and patients was surprising. The authors of the study expected younger and more educated patients to be more optimistic about the project, since these patients would be more technologically savvy and feel they deserve greater control over their care. Actually most patients, regardless of age or education, were very optimistic that the project would be helpful to their medical care, would help them understand their care better, and would give them more control over their care.

Physicians were much more restrained in their optimism. Doctors who opted into the program were obviously more optimistic than doctors who declined to participate, but many doctors in both groups expressed concerns that access to progress notes may increase anxiety and confusion among patients. It’s easy to imagine a patient presenting with symptoms which could be due to many different diseases. Doctors routinely document the many possibilities that will be tested and excluded or confirmed. Many of those possibilities are terrible diseases that will turn out not to be present. Will patients want to know before the test results are available all the scary possibilities? Patients expressed very little concern that reviewing progress notes will make them more anxious or confused. Is that because they are psychologically sturdier than doctors fear, or because patients are naïve about what they’ll be reading?

An accompanying editorial in the same issue describes the experience at M.D. Anderson which has already been offering all its patients online access to their entire medical record, including doctors notes. The editorial states that the M.D. Anderson experience has been largely positive. Patients appreciate having access to their notes, and feel better educated about their disease and treatment. They claim that impact on physician workflow has been minimal.

We’ll find out the results of the OpenNotes project in a year. As healthcare in general moves away from paper records, patients and physicians will have to struggle with balancing transparency with discretion, openness with privacy, and empowerment with guidance.

Learn more:

Patients Want To Read Doctors’ Notes, But Many Doctors Balk (Shots, NPR’s health blog)
Do you want to see what doctors write about you? Apparently, you do (Booster Shots, LA Times health blog)
Inviting Patients to Read Their Doctors’ Notes: Patients and Doctors Look Ahead (Annals of Internal Medicine article)
Access to the Medical Record for Patients and Involved Providers: Transparency Through Electronic Tools (Annals of Internal Medicine editorial)

Tangential Miscellany

The nice folks at the American College of Physicians Internist blog are republishing some of my posts. You’ll be happy to know that the fame hasn’t affected me yet.

I wish you a prosperous, healthy, and happy 2012!

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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December 23, 2011 | 12:18 pm

Don’t Put Unsterilized Tap Water Up Your Nose

Posted by Albert Fuchs, M.D.

I like introducing you periodically to some of the stranger and more dangerous germs out there. It’s a good reminder that nature isn’t just full of daisies and rainbows, and that the most lethal dangers we face are natural.

This week’s news presents a terrific example. Meet Naegleria fowleri. Naegleria fowleri is an amoeba, a single celled parasite that lives in warm bodies of fresh water, like lakes and rivers. Its nickname is the brain-eating amoeba. Isn’t that nice? (My nickname is Al.)

Before we find out why Naegleria (neg-LE-ria) is in the news, let’s get some background.

Infection with Naegleria is very rare. There have been 32 reported cases in the U.S. in the last ten years. Drinking water contaminated with Naegleria is perfectly safe, as Naegleria does not cause infection when swallowed. Naegleria only causes infection when contaminated water goes into the nose. Most cases have occurred in people swimming in fresh water lakes and rivers, frequently in southern states and usually in warmer weather. Some cases have also occurred in swimming pools that were not chlorinated.

When infection occurs, the amoeba crosses from the nasal sinuses into the brain and causes a disease called primary amebic meningoencephelitis (PAM) in which brain tissue becomes inflamed and is destroyed. As any neurologist or fan of zombie movies will confirm, destroyed brain tissue is bad. PAM is almost always fatal. It’s a good thing it’s so rare.

This week, a new mechanism for acquiring Naegleria infection came to medical attention. A woman in Louisiana became the second in the state to die this year from Naegleria that was likely acquired through the use of a neti pot. A neti pot is a small container shaped like a genie’s lamp that is used to flush water up the nose to clear nasal congestion. Many people with nasal allergies or colds prefer irrigating their noses and sinuses rather than taking decongestants. This is an important reminder that nasal irrigation should always be done with sterilized water – water that has been boiled or filtered. Unsterilized tap water is not safe for nasal irrigation. Remember, Naegleria in drinking water is perfectly safe, unless it’s flushed up the nose.

The Louisiana Department of Health published a press release warning of the potential danger of using neti pots with unsterilized water. The alert reminds us that neti pots or other nasal irrigation systems should be washed between uses and allowed to air dry. This effectively kills any amoeba in the equipment.

So if you are going to flush water up your nose, either buy sterile saline from your drug store, or boil some tap water first.

Finally, should we worry about swimming in lakes or rivers? Perhaps, but not because of Naegleria. Of the tens of thousands who swam in bodies of fresh water in the last decade in the U.S. only 32 developed Naegleria infection. During the same time period, there were over thirty thousand deaths due to drowning.

Learn more:

Neti pot danger? Two die from amoeba infection (Booster Shots, LA Times Health Blog)
Second Neti-Pot Death From Amoeba Prompts Tap-Water Warning (Shots, NPR Health Blog)
North Louisiana Woman Dies from Rare Ameba Infection (State of Louisiana Department of Health & Hospitals)
Naegleria, Frequently Asked Questions (Centers for Disease Control and Prevention, Parasites)

Tangential Miscellany

Lighting the darkness is a major theme of Hannukah. The holiday falls close to the winter solstice, when nights are the longest, and it always includes the night of a new moon, when the night is darkest. Increasing numbers of candles are lit every night and the menorah (candelabra) is placed by a window to be visible from the outside. It is a conscious rebellion against the cards dealt to us by nature. As the world gets darker, we illuminate our small corner of it and push back the night.

I hope in the last year my posts have illuminated a few dark topics for you. Thank you for reading. To everyone celebrating, Merry Christmas and Happy Hannukah!

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment

December 16, 2011 | 7:28 am

The Final Chapter

Posted by Albert Fuchs, M.D.

“Soon I will rest, yes, forever sleep. Earned it I have.”—Jedi Master Yoda

I have some bad news for you. You’re going to die.

Not soon, I hope. But for the foreseeable future the death rate will remain one per person.

This week a patient pointed me to a wonderful article by Ken Murray, “How Doctors Die”. Dr. Murray, a USC Family Medicine physician, argues that doctors faced with terminal illnesses very frequently forego aggressive care and die peacefully at home, while other patients are subjected to invasive, painful, and futile care at the end of life. I urge you to read the article. In fact, you might want to read it first and then return to this post.

All doctors have seen cases of patients receiving invasive, aggressive, futile care. Some cases involve not just care that is unlikely to help, but care that has been shown in studies not to help, like feeding tubes placed in patients with dementia, or CPR performed on patients dying of cancer. This is a calamity because it subjects patients who are frequently frail and in the final days of their lives to gratuitous suffering without any potential benefit. Worse, as if the suffering of the patients’ disease was not bad enough, the suffering due to futile care is inflicted by physicians. Though Dr. Murray also highlights the astronomical cost of futile care, I think the economic argument is unnecessary and counterproductive. These cases are a calamity even if the care was free. Patients should understand that we are appalled at such outcomes because of the harm done to patients, not because of the wasted resources.

Dr. Murray describes the problem well and recommends the path frequently chosen by physicians when they themselves are ill – hospice care, a focus on quality of life, and death at home. But how do we convince patients that this is best? Many patients believe that medical technology is omnipotent, and that recommendations for hospice care amount to giving up. Other patients, bewildered by the complexity of healthcare delivery, suspect that doctors have a financial motive to withhold lifesaving care. These misunderstandings can only be reversed if there is trust between patient and doctor.

Doctors, of course, share much of the blame. Ordering another test, recommending another procedure, and prescribing another medicine are all easier than giving a patient and her family terrible news. Maintaining a false hope is easier than explaining that this illness will be the last.

The best patients can do is to tell loved ones their wishes in advance, and develop a long-term relationship with a doctor they trust.

The best doctors can do is be honest when things are dire, and recommend against futile care with patience and compassion.

“May you die well.”—Klingon benediction

Learn more:

How Doctors Die (Zócalo Public Square)

My previous posts about end-of-life care:

When Less Care is More

A Dose of Realism about Advanced Dementia

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment

December 9, 2011 | 3:41 pm

A Reminder to Dump Your Multivitamin

Posted by Albert Fuchs, M.D.

The Medical Letter is a biweekly publication which publishes the most unbiased reviews of medications. It is not supported by advertising and prides itself in giving objective evidence-based information. I think it’s mandatory reading for anyone with a prescription pad. Several of my posts have been inspired by Medical Letter articles, and this week they’ve come through again with a review of vitamins titled “Who Should Take Vitamin Supplements?” The article reviews in detail the clinical trials which have tested the effects of the most commonly taken vitamins. I summarize these below.

Vitamin E supplements have been shown to increase the risk of prostate cancer, not to decrease the risk of stroke or heart attack, and not to decrease the risk of eclampsia in pregnancy.

Beta-carotene is a precursor of vitamin A. A randomized trial in smokers found that a high dose beta-carotene supplement significantly increased the risk of lung cancer. Another randomized study in asbestos workers showed that supplementation with vitamin A and beta-carotene led to higher lung cancer rates than placebo.

Vitamin D is essential in older people in preventing fractures and falls. Many people with limited sun exposure are deficient in vitamin D.

Vitamin C has been shown not to prevent the incidence of cancer, strokes, or heart attacks. It does not significantly decrease the risk of developing a cold or significantly improve cold symptoms. High doses can predispose to kidney stones.

Vitamin B12 deficiency is common in older patients and can lead to anemia and nerve dysfunction.

Folate should be taken by all child-bearing-age women to prevent neural tube defects in their babies. Folate supplementation has no known benefits in men.

Vitamin B6 supplementation has been proven not to decrease the incidence of strokes, heart attacks, or any cancer.

The authors conclude:

“In healthy people living in developed countries and eating a normal diet, the benefit of taking vitamin supplements is well established only to ensure an adequate intake of folic acid in young women and of vitamins D and B12 in the elderly. There is no good reason to take vitamins A, C or E routinely. No one should take high-dose beta-carotene supplements. Long-term consumption of any biologically active substance should not be assumed to be free from risk.”

That last sentence deserves our attention. Many people assume that even if vitamins aren’t helpful, they are at least harmless. The Medical Letter reminds us that this assumption should be tested, and when tested is sometimes proven false.

Learn more:

More Than Half of Americans Take Dietary Supplements (My post in April on multivitamins)
All my previous posts on various vitamins
Who Should Take Vitamin Supplements? (The Medical Letter article, issue 1379, only by subscription)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment

December 2, 2011 | 4:49 pm

Niacin Much Less Helpful in the Age of Statins

Posted by Albert Fuchs, M.D.

Niacin has been getting some bad press recently. A brief retrospective of Niacin’s rise to prominence will help us understand its recent fall from favor.

Niacin is also known as vitamin B3 or nicotinic acid, a molecule that we need in tiny quantities in our food. As far back as the 1950s it was known that niacin in higher doses reduces blood levels of cholesterol. At that time our understanding of heart disease was in its infancy and there were few effective medications to treat or prevent cardiovascular disease.

From 1966 to 1969 a trial called the Coronary Drug Project (CDP) was conducted that would prove to be niacin’s finest hour. The CDP enrolled patients who had suffered a prior heart attack and randomized them to placebo or niacin. My understanding of those years suggests that all the patients wore paisley shirts, had very long hair, rioted outside political conventions, and landed on the moon. The trial showed a reduction in strokes and heart attacks of about 25% in the patients receiving niacin. The CDP findings from over 40 years ago are the strongest suggestion we have that niacin helps prevent cardiovascular disease. The important thing to remember about the CDP is that many of the medications that are now used routinely in patients with heart disease, like aspirin and certain blood pressure medicines (beta blockers) were used rarely then. But that’s not surprising. After all, back then we thought that polka dots and hair were attractive in any quantity. Can you dig it?

Fast forward twenty years. The paisley and polka dots were replaced by skinny ties and Ray-Bans. The first statin, lovastatin (Mevacor), appeared on the market in 1987. My regular readers know that statins are a family of cholesterol-lowering medications which have been extensively proven to prevent strokes and heart attacks. Statins are also the most potent reducers of LDL, the cholesterol molecule most linked to stroke and heart attack risk. Meanwhile, other medications like aspirin and beta-blockers were proven to extend life and prevent heart attacks in people with prior heart attacks. The management of heart disease was progressing by leaps and bounds, and mortality from heart disease has been decreasing ever since.

So statins rapidly overshadowed niacin for management of cholesterol, and for good reasons. Niacin has side effects that are more difficult to tolerate, it lowers cholesterol less, and the evidence of its ability to prevent strokes and heart attacks is largely from one study – the CDP. Nevertheless, niacin has continued to be prescribed, largely because it has one benefit that statins don’t have. Niacin elevates the levels of HDL, a cholesterol molecule that is associated with lower heart attack and stroke risk.

This year a large trial called AIM-HIGH attempted to answer whether niacin taken with a statin is superior to a statin alone in patients with cardiovascular disease and low HDL. I wrote about the AIM-HIGH study in May when it was completed but before the full results were published. The full results were finally published two weeks ago. (You may want to read my May post for details about the study and for a more detailed explanation of LDL and HDL.)

The study enrolled patients with known cardiovascular disease with low HDL and randomized them to two groups. One group received a statin (simvastatin, sold under the brand Zocor) and niacin. The second group received simvastatin and a placebo. The niacin group had lower LDLs, higher HDLs, and lower triglycerides than the placebo group. But surprisingly there was no difference between groups in the rate of strokes and heart attacks.

What does this mean? Why didn’t better cholesterol numbers translate to better outcomes?

The first possible explanation (which I offered in May) is that low HDL is simply a marker of heart attack risk, not a cause. This is the same reason that putting an ice cube on your thermometer on a very hot day won’t make you feel more comfortable, since the thermometer reading is a marker for your discomfort, not a cause. Another explanation is that niacin alone does have some benefit (as shown in the CDP) but that the benefit of more modern medications is much greater. And that in the presence of statins and aspirin and other proven medications, niacin may not offer any additional advantage. Both explanations may be true.

So we’re likely seeing the waning days of niacin use. It may remain a reasonable option for patients who can’t tolerate statins. For the majority of patients who can tolerate statins, niacin has no value.

Learn more:
No Benefit From Niacin for Heart Patients in Study (US News)
Niacin in Patients with Low HDL Cholesterol Levels Receiving Intensive Statin Therapy (New England Journal of medicine article)
Niacin at 56 Years of Age — Time for an Early Retirement? (New England Journal of Medicine editorial)
Needed: Pragmatic Clinical Trials for Statin-Intolerant Patients (New England Journal of Medicine editorial)
Niacin Does Not Prevent Strokes or Heart Attacks (my post in May about Niacin)

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

0 Comments — Leave your comment