June 2022 Health Matters
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Health Matters June 2022

July 10, 2022   |   By Matt Van Auken

Announcements

Dr. Chad Muncrief will be leaving GreenField to follow his entrepreneurial dreams. His last day at GreenField will be Thursday June 16th. A letter was sent to his patients however, if you have questions or concerns please call our office at 503-292-9560. Thank you to Chad for his years at GreenField, we will miss him and wish him the best in his future.

Reminders

Changes to Annual Wellness Visits

As of the 2022 calendar year, some insurance-mandated changes require that all annual wellness visits will be preventive-only going forward. This means that while you may have new concerns or updates on chronic issues to discuss at annual wellness visits, separate appointments will need to be scheduled for those concerns. Please do not hesitate to bring your concerns up to your provider, though - even if those will require an additional visit or two, we will ensure that these are addressed in a timely and thorough manner.

GreenField On Call for You 24/7

The clinical team at GreenField is on call for all of our patients 24 hours a day, 7 days a week. That means that if you have any pressing need, question, or concern regarding your health, you can call on us at any time, and a clinician will be available to respond. Call support is available for patients of all ages. This is a benefit that we take pride in offering all GreenField members, and is one way we keep our commitment to reliably serving you. It is also one way we can help limit sometimes unnecessary/expensive/unpleasant trips to urgent care or the ER. Please do not hesitate to call us after/off hours when you need us!

Medication Side Effects: Statins

Although often thought of as medications to treat cholesterol, statins are a class of medications used more often to prevent heart and vascular disease when risk factors are present. They do have LDL and total cholesterol-lowering activity. However, given the person-specific nature of the cholesterol/heart disease relationship, it seems that they also have some preventive value beyond cholesterol alone. Some studies have shown that they exert anti-inflammatory effects in the vasculature, which may explain some of the benefit. Examples of statins include Lipitor (atorvastatin), Zocor (simvastatin), Crestor (rosuvastatin), Mevacor (lovastatin), Pravachol (pravastatin), and others. This class does not include nystatin, which is an anti-fungal medication. Statins are used very commonly for both primary and secondary prevention of cardiovascular and cerebrovascular disease, and thus, it is prudent to be aware of their side effects.

Muscle toxicity is the main side effect with statin treatment, and it can occur to varying degrees. Muscle injury associated with statin therapy ranges from muscle aches (myalgias) to muscle inflammation (myositis) to muscle breakdown (rhabdomyolysis). These effects are more common and often more severe the older a person gets, so it is possible to tolerate a statin initially and tolerate it well, and then eventually become less tolerant. We can measure more severe muscle injury with a blood test called creatine kinase (CK), an enzyme found in muscle cells that is released into the blood when muscles are damaged. More mild-to-moderate cases need to be assessed clinically by taking a history and doing a basic physical exam, since CK tends not to be elevated in the vast majority of those.

The incidence of myalgias, or muscle aches, ranges from about 2-10% of individuals on a statin. According to some earlier studies, this is similar to the incidence of myalgias in individuals treated with a placebo. More recent studies, though, suggest that there can be an autoimmune component to some statin-related myalgias, which is difficult to test for and complicates the picture somewhat.

The incidence of myalgias, or muscle aches, ranges from about 2-10% of individuals on a statin. According to some earlier studies, this is similar to the incidence of myalgias in individuals treated with a placebo. More recent studies, though, suggest that there can be an autoimmune component to some statin-related myalgias, which is difficult to test for and complicates the picture somewhat.

What are some of the risk factors for myalgias and myopathy (progressive muscle weakness)? Enhanced susceptibility to statin-associated myalgias and myopathy occurs in patients with chronic kidney failure, chronic liver disease, and untreated hypothyroidism among others. The risk of myopathy is also increased with the simultaneous use of certain other drugs, particularly the following:

  • Niacin (Slo-niacin, Niaspan) - a lipid-lowering medication
  • Gemfibrozil (Lopid) and fenofibrate (Tricor) - lipid-lowering medications
  • Erythromycin, azithromycin (Zithromax), and clarithromycin (Biaxin) – the class of macrolide antibiotics
  • Digoxin (Lanoxin) – a medication used in heart failure and cardiac arrhythmias such as atrial fibrillation
  • Itaconazole (Sporanox) – an antifungal medication
  • Warfarin (Coumadin) – a blood-thinning medication
  • Cyclosporine - an immunosuppressive drug most frequently used in transplantation
  • Certain antiviral drugs used in HIV infection and other special cases of viral infection

Frank myositis, or muscle inflammation, is defined as a CK elevation more than 10 times normal in association with muscle symptoms, and it occurs in less than 0.5% of individuals on a statin. Severe myositis causing muscle aches, weakness, and decreased exercise tolerance affects only about 0.1% of treated individuals.

Rhabdomyolysis (muscle breakdown potentially associated with permanent muscle injury and acute kidney failure) caused by statins is an extremely rare complication generally only seen in individuals who have other risk factors. Death due to statin-induced rhabdomyolysis averages only about 0.15 per million prescriptions. Put another way, that’s 15 out of every 100 million people.

Statin-associated muscle symptoms usually occur within the first few months after starting treatment therapy, but may occur at any time during treatment. The incidence of muscle side effects is associated with the dosage – higher dosages more commonly cause muscle injury. The effects are generally reversible - muscle aches and weakness resolve and CK concentrations return to normal over a few days to a few weeks after discontinuation of the medication.

Despite the risk of various myopathy associated with statin therapy, routine monitoring of CK levels is not recommended. If you are on a statin, the most important thing is to be aware of the possibility of myopathy. If you develop generalized muscle aches, tenderness, or weakness, stop taking the statin and let us know right away, as that might be a reason to test. It also may be a reason to switch therapies (see below).

Statin-induced liver disease can occur as well, though like rhabdomyolysis, severe forms of this complication are very rare less than (0.01%). Routine monitoring of liver function blood tests is no longer recommended except in those individuals with pre-existing liver disease. There even appears to be some preventive benefit to using statins in folks with type 2 diabetes and non-alcoholic fatty liver disease, as they may stop or partially reverse fatty and scarring changes to the liver.

Of course, for many individuals, much of this conversation can effectively be rendered moot with evidence-based lifestyle interventions. Statins are effective at slowing and sometimes halting the progression of cardiovascular and cerebrovascular disease; however, the only intervention that has ever been shown to reverse existing cases of these issues (and is also effective for reversing type 2 diabetes and non-alcoholic fatty liver disease) is a whole-food, plant-based diet, particularly in the context of adequate physical activity and stress reduction.

If you have new symptoms on a statin and they are mild, please discuss with us. We will often switch to a different statin medication, which frequently resolves the issue. A non-synthetic source of statin, such as red yeast rice (RYR) can also be considered, as it is common for those who do not tolerate synthetic statins to tolerate RYR without issue.

If you have questions or concerns about a statin medication you might be taking, or if you are wondering whether statin therapy is right for you, or if you would like to know about lifestyle-based reduction of cardiovascular and cerebrovascular disease risk, be in touch with your GreenField team. This is what we’re here for!

https://pubmed.ncbi.nlm.nih.gov/32233708/

https://pubmed.ncbi.nlm.nih.gov/33716004/

https://pubmed.ncbi.nlm.nih.gov/30652643/

https://pubmed.ncbi.nlm.nih.gov/32139553/

Alcohol and Heart Disease Risk: An Update

For a long time, non-randomized epidemiological studies suggested that there might be an association between light-moderate alcohol intake (up to 1-2 alcohol-containing beverages per day) and a reduced risk of heart disease.

This was the most compelling evidence we had. For some key background, randomized, placebo-controlled, double-blinded studies are considered the gold-standard for evidence in medicine. However, because it is very hard to blind individual people to drinking alcohol (generally, the presence of alcohol is not a secret to the drinker) - and also because it is hard to conduct studies on very long-term outcomes like heart disease - it is essentially not possible to achieve this level of evidence in this case. Ergo, we have to rely on longitudinal epidemiological studies for evidence.

Enter a study published March 25, 2022 in JAMA Network Open. In this cohort study, more than 370,000 UK individuals’ health habits, including alcohol consumption, were analyzed. In working through the data, the researchers found that all alcohol consumption was associated with increased risk of cardiovascular disease and related outcomes (hypertension, etc.), and that the risk increased with the amount of alcohol consumed (in other words, the more alcohol consumed, the higher the risk).

Yes, you read that correctly: any amount of alcohol intake was associated with an increased risk of heart disease. The more alcohol, the higher the risk.

But can this be right if prior studies found the opposite?

The answer may well be something close to a resounding “yes.” In their analysis, the study authors found that light-to-moderate alcohol intake was strongly associated with lifestyle factors (diet and exercise habits, less smoking, etc.) that themselves are connected to lower cardiovascular risks. In other words, all this time, it is possible that the association between light-moderate alcohol use and lower cardiovascular risk was not an association at all. Instead, this finding may have been due to the confounding factors of healthier diet, more regular cardiovascular exercise, and so on.

Notably, the authors are clear that there may be some not well-accounted for genetic bridge that could partially explain both greater alcohol use and cardiovascular disease risk, but to explain away the link between alcohol use and heart disease risk on this basis entirely would be a stretch.

So - what now? And what about wine? Wine is different, isn’t it?

Let’s attempt to answer the second question first: what makes wine special isn’t the alcohol. If it was the alcohol, all alcohol would be healthy to consume across the board. And let’s be real: there’s no way of spinning beer or vodka consumption as healthy for the body. Instead, it’s the stuff found in grapes themselves. Compounds like the bioflavonoids and phytophenols in grapes, such as resveratrol, are known to exert some benefits that may reduce cardiovascular disease risk. These include, notably, a tendency to support lower blood pressures in those prone to high blood pressures. Eat grapes (whole, with the skins), or dark-colored berries, for that matter, and you get tons of these - all with the added bonus of the fiber content, the molecules like lignans found in the seeds (unless eating seedless, so here’s a plug for eating grapes with seeds), and the absence of an intoxicant like alcohol. In other words, eat the whole foods, get the benefits and skip the morning-after syndrome.

And to begin to answer the second question: for health benefit, perhaps consider enjoying more herbal tea with dinner instead.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2790520?resultClick=1

Your GreenField Integrative Physician, Dr. Matt Van Auken
And the entire team at GreenField Health