Yehuda Handelsman Part 3, Managing LDL of Patients

In part 3 of this Exclusive Interview, Dr. Yehuda Handelsman talks with Diabetes in Control Publisher Steve Freed during the AACE 2017 convention in Austin, Texas about managing LDL, his LDL recommendations according to the patient and varying health events.

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: So, you say the new guidelines will say that a person with diabetes, they should try to get their LDL…

Yehuda: What we are saying is this: the lower the LDL the better. The different risk groups that we have, let’s say somebody has diabetes and has a couple of risk factors. We would say LDL less than 70 would be okay. Somebody who doesn’t have diabetes who had a heart attack, we would say LDL less than 70. But if somebody has diabetes and a heart attack or somebody had kidney disease and heart attack or heterozygous FH and heart attack, to these groups we say even lower, even 55. So, the lower the risk group, the higher the LDL can be. We also address triglycerides and other stuff in the guidelines, but this is like the new stuff. New stuff is extreme risk group with much lower and the fact that we now have evidence to support combination therapy to get patients to goal. That’s very important. So it’s not statin alone anymore. We have got two keys to the market: ezetimibe and now the PCSK9 in addition to a statin. That can get us to the lower goals and to the better outcomes.

Steve: So, for someone who is at a high risk who has had a heart attack, and you want to get them to a at least 55 or below…

Yehuda: That depends. If somebody had a heart attack, their goal should be around less than 70. But let’s say they are at 67 and they keep having events, then I want them below 55.

Steve: Can you do that with the standard lipids that are available today without the new ?

Yehuda: I don’t know. Some yes, some not. All the PSCK9 are revolutionary. Here is the point, if they would cost $5 a month, there’s no question there. They’re going to give it. Very nice drugs, seemingly very safe, we have four years of data to show safety and that’s really starting to accumulate. They can get our patients to very low goals and they can reduce heart attacks by now by at least 25%. Somebody will need to evaluate events in life. I am not there you know. I recognize it’s a big burden. I also don’t think everybody needs to have that. And the other ways to mitigate risk that we can work with. But there will be patients that need to have this drug and they are expensive but you know what? Drugs for rheumatoid arthritis are very expensive. Drugs for mental disorders are very expensive. Drugs for hepatitis C are very expensive. You know metformin used to be expensive, actos used to be expensive and then they become generic. Sooner or later these new drugs will be less expensive. We need to take them into account and there always will be a time that any insurance company, any person, any government needs to say what is the value of the life of the person across from me? And this is a big question. How do you answer it? If you know that you can reduce the chances of getting heart attacks and stop it from going on. I have a musician patient. Not musician, he actually big music producer for movies, you know I am from Los Angeles, so in Beverly hills in Hollywood actually. And the guy has diabetes and guy had a stroke and some how got out of stroke…mentally okay and physically not as good and then his LDL with statins. He was on rosuvastatin and he was also tried ezetimibe and he was okay with it to a point. LDL was in low 70’s and then he get an acute coronary syndrome. So the fear is not another acute coronary syndrome, it’s another stroke that takes him out of business at all. So we started him on medication and so his LDL now is down to less than 40. And in the past year, he did not have any event. Did we do that? Did life do that? I don’t know. But at least we tried to stop the down spiral road that he was on.

Steve: So, for patient who has diabetes and one coronary situation, you are still satisfied with around 70 LDL?

Yehuda: If they had an event, then no. if they have severe risk, then 70 is fine. If somebody had diabetes with high blood pressure and some lipid disorders and they did not have a heart attack or any kind of an event, then I am okay with less than 70.

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