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Yehuda Handelsman Part 1, Interpreting Lipid Guidelines

In part 1 of this Exclusive Interview, Dr. Yehuda Handelsman talks with Diabetes in Control Publisher Steve Freed during the AACE 2017 convention in Austin, Texas about interpreting lipid guidelines and the reasoning behind changes to cholesterol goals.

Yehuda Handelsman, MD, FACP, FACE is a past president of the American College of Endocrinology and Medical Director of the Metabolic Institute of America in Tarzana, CA.


Transcript of this video segment:

Steve: This is Steve Freed with Diabetes in Control and we are here with a very special guest. Dr. Handelsman who is very well known. He’s actually past president of ACE (American College of Endocrinology) and chair of ACE DM with lipids. He has published over 100 papers. So, he is very well known and everybody out there I am sure knows his name. Now you get to meet him in person.  I know you are here to receive an award. What kind of award?

Yehuda: That’s kind of cool. Thank you for even mentioning that. With all the stuff that we are doing, it kind of escaped me for a second until people come and say congratulation. So, this is the Master of the American College of Endocrinology. So American college of endocrinology has won some awards. It recognizes person for its contribution to the field of endocrinology and to ACE, both AACE the association and the college.

Steve: In the title of your talk is “Interpreting Lipid Guidelines: How Low Should We Go?” That’s an interesting topic because ACE’s changed their guidelines many times and it gets a little confusing sometimes. So how low can you go? Maybe you can give us some high points about that. What do you want people to take away from this meeting and from your presentation?

Yehuda: I think that ACE has been quite consistent with early recommendation with ATP3 and CP4, and NIH sponsor accommodation for managing lipids suggesting to go to lower goals of LDL to prevent cardiovascular disease. Some other groups, like American College of Cardiologists few years ago came out and said that goals are not that important. What’s more important is just giving somebody a statin. Now we believed that we need to give statin to the patient. The question is, do all patients act the same? And we used to have several risk categories. The risk category which is low, moderate then high then very high. Very high person could have been somebody who’s got diabetes and couple of risk factors and somebody who once had a heart attack. And may have another one. How should we treat them? We used to recommend to get to goals lower than 70. The American College of Cardiologists came with the guideline. We did not change ours. It says you give them high potency statin, suppose Lipitor 40 or 80mg, or rosuvastatin 40mg. And don’t worry about the goals. Because that’s all you can do. Don’t do combination therapy. And then we were seeing in practice that people get to those goals sometimes or don’t even go to the goals and they keep having events. So, we went ahead and examined the available data. We got a group of experts looking over older guidelines from 2012 looking at other guidelines over there, looking at new data coming in. And data came in to show that really the lower the LDL cholesterol, the better outcome patients had. So, it’s just not a miracle of statin, which we think should be very important, but it’s a fact that we need to get the people to goal. In nearly 50% events, some even less, by other analysis only 30% of patients needs to have an LDL below 70 because they have such a high risk even getting at goal. What we also saw that there were some groups of patients with particular risk. Person with diabetes who already had an event; person with kidney disease who had an event. Somebody with familial hypercholesterolemia who had stroke and couple of other heart events and they may be at a goal of 70 but that may not have been enough. So, we created a new risk category and that’s what’s very new in our guidelines. First time in 14 years there is a new risk group, which is called extreme risk. So, we didn’t want to call it extreme high because there is moderate high, medium high, there is high, very high or extreme risk. And extreme risk are exactly the patient they talked about. People with diabetes, kidney disease or heterozygous familial hypercholesterolemia and these group of people we believe should have more a intense goal, looking at a goal of LDL less than 55. Also looking at ApoB, which is another measurement of risk. We said that could be less than 70. When we can look at goal of non-HDL, we said less than 80. So, all these goals represent a good place for using events in extreme-risk patients. And when we devised that there was one randomized progressive trial, it’s the improvement they showed the patient who got to LDL of 53 had less events than patients with LDL of 69. Not only that, the majority of the events – but that’s a post hoc analysis,  so it’s not as scientific as we would like – but the majority of the people were people with diabetes. Hence, extreme risk group. Various other meta analysis showed very similarly the lower you go, the better it is. So, we went ahead and published our guidelines and it’s still in print this week. And in March, American College of Cardiology there is a trial with a new drug, PCSK9 inhibitors, which is really a 21st century drug. We look at this drug and took patients with high risk for secondary prevention and they reduce LDL down to about 30-32 LDL and reduced heart attacks by 27%. So, you take very high risk people, very well treated they were on stopped statin 80 lipitor, 40 rosuvastatin and they were getting ACE inhibitors and ARBs, beta blockers and top top treatment and even in the treatment group, there was further reduction in MI to say that we really need to focus on people to getting to lower goal especially LDL. And especially in people with diabetes. Because the LDL of a person with diabetes is different than the LDL of people that don’t have insulin resistance and obesity. There are many more particles with this number of 65 compared to someone who doesn’t have it. And I think that’s why people with diabetes are doing better.

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