BBRA's A Doctor's Corner.
BBRAsearchYOUR RIGHT TO KNOW
Reported February 28, 2009
Filtering Out Bad Cholesterol -- In-Depth Doctor's Interview
Do you see a lot of patients with cholesterol problems?
Dr. Goldberg: I see a lot of people with cholesterol problems. One of my interests is a problem called familial hypercholesterolemia, which is an inherited disorder of cholesterol, where people have very high levels of LDL cholesterol, the bad cholesterol, which leads them to be at high risk of heart disease, coronary artery disease.
Do you think high cholesterol is more genetic or environmental?
Dr. Goldberg: It is genetic. This is a genetic problem. The environment plays a small role. About 10 to 20 percent of the high cholesterol level can be related to high saturated fat food that a person eats.
When do high cholesterol levels typically show up?
Dr. Goldberg: People who are born with cholesterol levels that are high, from birth, and they pretty much double the normal number of cholesterol. It ranges anywhere from 250 to 500 with single gene inheritance. If you got a double dose, if you got a bad gene from both parents, you can end up with a child with cholesterol at 600 to 1000 from birth. Those kids are in big trouble because they tend to get very early vascular disease, and unless you start treating them fairly soon, they can end up with heart disease by the time they are in their teens.
Do lifestyle changes help people who are born with high cholesterol?
Dr. Goldberg: The better diet does help, but it is not going to lower their cholesterol levels to normal, and they all need medication. If medications are not enough to get the cholesterol down to where you want it to be, or if they cannot tolerate enough medication to get the cholesterol low enough, then that is where the LDL apheresis procedure comes in.
Tell me about this procedure.
Dr. Goldberg: This is a procedure that is done every two weeks and you take out blood from the person, you separate the blood into the liquid part of the blood and the red cells. The liquid part of the blood is interacted with a compound called heparin, and then that gets run over by a column that acts like a sieve almost, and it basically grabs on to the bad cholesterol, and removes it directly from the blood. Then you put the liquid portion of the blood back together with the red blood cells and put it back to the patient. You are filtering out the bad cholesterol.
How long does it take to do this?
Dr. Goldberg: The length of time it takes is about an hour and a half to two hours for the patient. It takes some time, at least half an hour to an hour to set it up beforehand.
Is this something patients will have to do for the rest of their lives?
Dr. Goldberg: Generally, people are on this indefinitely unless something else comes along that they are able to tolerate that lowers their cholesterol. There are always new things, medications being worked on.
Are the results seen immediately?
Dr. Goldberg: We test cholesterol before and after. If you test the cholesterol before and the LDL is 200, at the end of the procedure, we draw another blood sample and the LDL cholesterol is down to 70 or 80. Normal optimal LDL is under 100.
So is this a cure for high LDL?
Dr. Goldberg: It is not a cure because the LDL goes back up again. The constant production over time leads the levels to go up again, and so you do it every two weeks.
Is this treatment hard on the body?
Dr. Goldberg: No, changing the LDL levels is not a problem, and the amount of blood that is actually processed at any given time is not very much.
How does lowering LDL help a patient?
Dr. Goldberg: You are decreasing the risk of heart disease in the person by lowering the LDL. People have been doing it for a long time, for quite a few months, some of them have a decrease in their heart symptoms. Or some people who have problems with poor blood flow to their legs often have that symptom get better and then they can walk longer.
Have you seen anything work this quickly and be this efficient before?
Dr. Goldberg: This is the most efficient process for lowering LDL, because it happens immediately.
What's the standard treatment for a patient with high LDL?
Dr. Goldberg: The standard of care is one or more medications to lower LDL, and most people are going to be able to get their LDL cholesterol levels down with one or more medications. So the people who have starting LDLs of 250, 300, 400. I am treating with drugs called statins plus additional medications. It is going to be a fraction of people who simply cannot get the levels down with the amount of medications they can tolerate who are candidates for this. The requirements are that if you have vascular disease, if you have heart disease, blockages in the various arteries, and an LDL over 200 on as much medication as you can take. For people do not have heart disease already, so people who are younger and may have the vascular disease already, it's an LDL cholesterol of over 300.
Is Ted one of the most extreme cases you work with?
Dr. Goldberg: His starting numbers are fairly high, but I have people who have higher cholesterol levels than that without any treatment. So he falls into the category of the people who are quite severely affected.
How common is it for people to inherit this extremely high LDL?
Dr. Goldberg: A lot of it is genetic, but not everybody has this severe genetic problem. This problem, the severe inherited high cholesterol problem, affects one in about one in 500 people. Which is a lot, if you have a major metropolitan area of a million people or so, then you are talking about, you know, a couple thousand people in the area. Almost all of them should be on medication at the very least.
How do you know if you have the gene?
Dr. Goldberg: Before people have heart disease, they may not have any symptoms of the high cholesterol, and one of the things is to look at the family history, and then if there is a bad family history of heart disease, to screen everybody, including the kids. If you have one of the family trees that are typical of this, which is male relatives with heart disease in their 30s and 40s, and women in their 40s and 50s and 60s, then you may have this disorder and it is worthwhile screening younger people. If your father had a heart attack at 35, you do not want to wait until 25 to start treating, you want to start treating people in their teens.
How early would you screen?
Dr. Goldberg: I generally start screening by about age 5.
And you are treating people at age 5?
Dr. Goldberg: I usually start the very young kids with diet, and then I start medication some time in the early teens.
Are there any drawbacks to the new treatment?
Dr. Goldberg: It is costly because the materials are costly.
Does insurance cover it?
Dr. Goldberg: It is covered by insurance. It actually has a set of guidelines through Medicare, and most insurance companies follow Medicare.
END OF INTERVIEW