Bring 'bad' cholesterol down, regardless
Research suggesting a link between low levels of LDL cholesterol and Parkinson's is preliminary

Dr. Andrew Weil, Vancouver Sun
Published: Monday, January 14, 2008

Q: I just read that if you have low LDL cholesterol, you have a higher risk of Parkinson's disease. Does that mean you shouldn't try to lower your LDL if you have a family history of Parkinson's?

A: Parkinson's disease is a neurological condition affecting the "substantia nigra," a small area of cells in the midbrain. Degeneration of these cells results in lower levels of the neurotransmitter dopamine (a brain-signaling chemical) and upsets the balance between dopamine and another brain chemical, acetylcholine. The most familiar signs of the disease are resting tremors, a generalized slowness of movement, stiff limbs, and problems with balance or gait. Depression is also common. In advanced cases, mental function can deteriorate. Parkinson's disease is progressive and incurable.

A small study from the University of North Carolina (UNC) at Chapel Hill suggests that people with low LDL (low-density lipoprotein, the "bad" cholesterol) are more likely to develop Parkinson's than those whose LDL is high. (As far as your heart is concerned, low LDL is good -- the lower it is, the lower your risk of heart disease.) The North Carolina researchers tested the cholesterol of 124 Parkinson's patients being treated at the UNC Movement Disorder Clinic and 112 spouses of clinic patients. They found that those with LDL levels of less than 114 (mg per deciliter) had a 3.5 times higher incidence of Parkinson's than study participants whose LDL was more than 138.

However, we don't know whether the Parkinson's patients' LDL was low before the onset of the disease. The researchers did determine that study participants with Parkinson's were less likely to have taken cholesterol-lowering drugs than those in the control group.

While these findings are interesting, the investigators described them as preliminary and called for larger studies to help clarify how LDL affects the risk of Parkinson's.

In the meantime, if your LDL cholesterol is high, you should follow medical advice to bring it down. After all, it's long been known that smoking is linked to a lower risk of Parkinson's, but it's certainly not a good idea to take up cigarettes to protect yourself from the disease. Keep the relative risks in mind: the incidence of Parkinson's disease is 12 to 20 cases per 100,000 persons per year. The incidence of heart disease is 1 in 12.

Iodine therapy

Q: I just had my thyroid removed due to papillary cancer. I am told that radioactive iodine to destroy the tiny remnant of thyroid tissue remaining after surgery is recommended, that it's "well tolerated" and has "no side effects." My research (and intuition) tell me otherwise! What is your opinion?

A: As I'm sure you know by now, the type of thyroid cancer you had is very slow-growing and very rarely fatal, particularly in younger people. Radioactive iodine is used to destroy any thyroid tissue that wasn't removed by surgery in order to be sure that all traces of cancer are eliminated. It is considered to be a safe procedure.

I discussed your case with Randy Horwitz, M.D., medical director of the Program in Integrative Medicine, and Merilyn Goldschmid, M.D., an endocrinologist; both are here at the University of Arizona. Both agreed that the use of radioactive iodine in cases such as yours is appropriate and carries low risk. Dr. Goldschmid advised a single dose of radioactive iodine and recommended that you drink plenty of fluids following your treatment to flush the iodine out of the salivary gland, the only gland beside the thyroid that can retain it. She and Dr. Horwitz also cautioned that women need to use contraception for about a year after the treatment, because radioactive iodine can affect the ovaries. Women's periods can become irregular for a while but should return to normal at the end of a year.

Side effects of radioactive iodine treatment are rare, but occasionally patients do experience some neck tenderness, nausea and stomach irritation, dry mouth and tenderness of the salivary glands (sucking on lemon drops can reduce this). There is a very small risk of developing leukemia in the future. In my view, the risk of the iodine treatment is much lower than that of leaving a bit of cancer behind following thyroid surgery. Therefore, I suggest that you follow your physician's recommendations and have the treatment. I know of no alternative that would serve you as well.

The views expressed in this column are the author's. Readers are advised always to consult their doctor for specific information on personal health matters. The naming of any product or therapy in this column does not represent an endorsement by The Vancouver Sun.

Ask Dr. Weil does not provide specific medical advice and is not intended as a substitute for the advice provided by your physician or other health-care professional. You should always consult your physician to discuss specific symptoms and conditions.

Readers who wish to ask Dr. Weil a question may do so by visiting his Web site, www.drweil.com, and clicking "Ask Dr. Weil" and then "Ask Your Question." Because Dr. Weil receives so many questions, it is impossible for him to personally respond to every query.

(page 1 and 2 of 6 page article from business week)
http://tinyurl.com/2spawz

Do Cholesterol Drugs Do Any Good?
Research suggests that, except among high-risk heart patients, the benefits of statins such as Lipitor are overstated
By John Carey

This Issue
January 28, 2008

Lipitor
Previous IssueNext Issue
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Martin Winn's cholesterol level was inching up. Cycling up hills, he felt chest pain that might have been angina. So he and his doctor decided he should be on a cholesterol-lowering medication called a statin. He was in good company. Such drugs are the best-selling medicines in history, used by more than 13 million Americans and an additional 12 million patients around the world, producing $27.8 billion in sales in 2006. Half of that went to Pfizer (PFE) for its leading statin, Lipitor. Statins certainly performed as they should for Winn, dropping his cholesterol level by 20%. "I assumed I'd get a longer life," says the retired machinist in Vancouver, B.C., now 71. But here the story takes a twist. Winn's doctor, James M. Wright, is no ordinary family physician. A professor at the University of British Columbia, he is also director of the government-funded Therapeutics Initiative, whose purpose is to pore over the data on particular drugs and figure out how well they work. Just as Winn started on his treatment, Wright's team was analyzing evidence from years of trials with statins and not liking what it found.

Yes, Wright saw, the drugs can be life-saving in patients who already have suffered heart attacks, somewhat reducing the chances of a recurrence that could lead to an early death. But Wright had a surprise when he looked at the data for the majority of patients, like Winn, who don't have heart disease. He found no benefit in people over the age of 65, no matter how much their cholesterol declines, and no benefit in women of any age. He did see a small reduction in the number of heart attacks for middle-aged men taking statins in clinical trials. But even for these men, there was no overall reduction in total deaths or illnesses requiring hospitalization—despite big reductions in "bad" cholesterol. "Most people are taking something with no chance of benefit and a risk of harm," says Wright. Based on the evidence, and the fact that Winn didn't actually have angina, Wright changed his mind about treating him with statins—and Winn, too, was persuaded. "Because there's no apparent benefit," he says, "I don't take them anymore."

Wait a minute. Americans are bombarded with the message from doctors, companies, and the media that high levels of bad cholesterol are the ticket to an early grave and must be brought down. Statins, the message continues, are the most potent weapons in that struggle. The drugs are thought to be so essential that, according to the official government guidelines from the National Cholesterol Education Program (NCEP), 40 million Americans should be taking them. Some researchers have even suggested—half-jokingly—that the medications should be put in the water supply, like fluoride for teeth. Statins are sold by Merck (MRK) (Mevacor and Zocor), AstraZeneca (AZN) (Crestor), and Bristol-Myers Squibb (BMY) (Pravachol) in addition to Pfizer. And it's almost impossible to avoid reminders from the industry that the drugs are vital. A current TV and newspaper campaign by Pfizer, for instance, stars artificial heart inventor and Lipitor user Dr. Robert Jarvik. The printed ad proclaims that "Lipitor reduces the risk of heart attack by 36%...in patients with multiple risk factors for heart disease."

So how can anyone question the benefits of such a drug?
For one thing, many researchers harbor doubts about the need to drive down cholesterol levels in the first place. Those doubts were strengthened on Jan. 14, when Merck and Schering-Plough (SGP) revealed results of a trial in which one popular cholesterol-lowering drug, a statin, was fortified by another, Zetia, which operates by a different mechanism. The combination did succeed in forcing down patients' cholesterol further than with just the statin alone. But even with two years of treatment, the further reductions brought no health benefit.

DOING THE MATH
The second crucial point is hiding in plain sight in Pfizer's own Lipitor newspaper ad. The dramatic 36% figure has an asterisk. Read the smaller type. It says: "That means in a large clinical study, 3% of patients taking a sugar pill or placebo had a heart attack compared to 2% of patients taking Lipitor."

Now do some simple math. The numbers in that sentence mean that for every 100 people in the trial, which lasted 3 1/3 years, three people on placebos and two people on Lipitor had heart attacks. The difference credited to the drug? One fewer heart attack per 100 people. So to spare one person a heart attack, 100 people had to take Lipitor for more than three years. The other 99 got no measurable benefit. Or to put it in terms of a little-known but useful statistic, the number needed to treat (or NNT) for one person to benefit is 100.

Compare that with, say, today's standard antibiotic therapy to eradicate ulcer-causing H. pylori stomach bacteria. The NNT is 1.1. Give the drugs to 11 people, and 10 will be cured.

A low NNT is the sort of effective response many patients expect from the drugs they take. When Wright and others explain to patients without prior heart disease that only 1 in 100 is likely to benefit from taking statins for years, most are astonished. Many, like Winn, choose to opt out.

Plus, there are reasons to believe the overall benefit for many patients is even less than what the NNT score of 100 suggests. That NNT was determined in an industry-sponsored trial using carefully selected patients with multiple risk factors, which include high blood pressure or smoking. In contrast, the only large clinical trial funded by the government, rather than companies, found no statistically significant benefit at all. And because clinical trials themselves suffer from potential biases, results claiming small benefits are always uncertain, says Dr. Nortin M. Hadler, professor of medicine at the University of North Carolina at Chapel Hill and a longtime drug industry critic. "Anything over an NNT of 50 is worse than a lottery ticket; there may be no winners," he argues. Several recent scientific papers peg the NNT for statins at 250 and up for lower-risk patients, even if they take it for five years or more. "What if you put 250 people in a room and told them they would each pay $1,000 a year for a drug they would have to take every day, that many would get diarrhea and muscle pain, and that 249 would have no benefit? And that they could do just as well by exercising? How many would take that?" asks drug industry critic Dr. Jerome R. Hoffman, professor of clinical medicine at the University of California at Los Angeles.

Drug companies and other statin proponents readily concede that the number needed to treat is high. "As you calculated, the NNT does come out to about 100 for this study," said Pfizer representatives in a written response to questions. But statin promoters have several counterarguments. First, they insist that a high NNT doesn't always mean a drug shouldn't be widely used. After all, if millions of people are taking statins, even the small benefit represented by an NNT over 100 would mean thousands of heart attacks are prevented.

That's a legitimate point, and it raises a tough question about health policy. How much should we spend on preventative steps, such as the use of statins or screening for prostate cancer, that end up benefiting only a small percentage of people? "It's all about whether we think the population is what matters, in which case we should all be on statins, or the individual, in which case we should not be," says Dr. Peter Trewby, consultant physician at Darlington Memorial Hospital in Britain. "What is of great value to the population can be of little benefit to the individual." Think about buying a raffle ticket for a community charity. It's for a good cause, but you are unlikely to win the prize.