Common Misconceptions about Lipid-Lowering Therapy: Scientific Understanding and Long-Term Management

In lipid-lowering therapy, is it true that the lower the blood lipids, the better?

Many people believe that blood lipids are harmful substances and should be as low as possible, but this is a misconception. Blood lipids play a vital role in maintaining normal physiological functions. Triglycerides are mainly involved in energy metabolism, releasing a large amount of energy for bodily activities. Cholesterol is a major component of cell membranes and plays a crucial role in stabilizing normal cell membrane function. At the same time, cholesterol is also an important raw material for the synthesis of hormones, vitamin D, and bile acids. Therefore, lowering blood lipid levels too much can affect normal physiological functions. According to the latest research, the ideal low-density lipoprotein cholesterol (LDL-C) level should be maintained between 1.30 and 1.82 mmol/L. Lowering blood lipid levels further can be considered while maintaining normal physiological functions. However, the appropriate level of LDL-C reduction for each patient should be determined by consulting a doctor, as target levels vary among different individuals.

Do patients with dyslipidemia need lifelong medication?

Dyslipidemia, like hypertension, requires lifelong medication. This is because lipid-lowering drugs don't address the root cause of dyslipidemia; they only block a certain intermediate step in the lipid-lowering process. Therefore, once medication is stopped, lipid levels will rise again after 4-6 weeks. Thus, it is recommended that patients with dyslipidemia take medication lifelong. Dosage reduction is possible depending on the situation, but a check-up every 3 months is necessary. If blood lipids remain normal after stopping medication, non-pharmacological treatment can be used to lower lipids. If blood lipids remain abnormal, medication must be continued.

Who should not use lipid-lowering drugs? The following individuals should not use lipid-lowering drugs:

① Patients with active hepatitis: Many lipid-lowering drugs are metabolized in the liver, which can worsen liver damage.

② Pregnant or breastfeeding women: Women with dyslipidemia should discontinue lipid-lowering drugs after becoming pregnant. Because atherosclerosis is a chronic process, discontinuing lipid-lowering drugs during pregnancy has minimal impact on the long-term effects of primary dyslipidemia. Furthermore, cholesterol and other products of its biosynthesis are essential components for fetal development, including steroid and cell membrane synthesis. Statins, while reducing cholesterol biosynthesis, also reduce other products of the cholesterol biosynthesis pathway, so pregnant women taking these drugs may harm the fetus. Whether lipid-lowering drugs and their metabolites are secreted in human breast milk is currently unknown. Therefore, it is best for breastfeeding women to avoid them.

③ Patients with malignant tumors. Finally, it should be emphasized that patients over 70 years of age, those with chronic heart failure, dementia, or advanced cerebrovascular disease should use lipid-lowering drugs with caution.

Can lipid-lowering drugs be discontinued arbitrarily? The goal of lipid-lowering therapy is to lower low-density lipoprotein cholesterol ("bad" cholesterol) levels, stabilize and reverse atherosclerotic plaques, and prevent the occurrence and development of cardiovascular and cerebrovascular events. After a period of treatment, cholesterol levels return to normal. However, to maintain the long-term stability of atherosclerotic plaques on the arterial walls, "bad" cholesterol must be kept within the target therapeutic range for an extended period. Dosage reduction or discontinuation of medication should not be done arbitrarily. Studies show that the clinical benefit of statins is related to the duration of treatment; the longer the treatment, the greater the benefit. When to stop medication, or whether to stop at all, should be determined by a doctor.

Will blood lipids rebound after stopping lipid-lowering medication?

There are many types of lipid-lowering drugs, but regardless of the type, they typically produce maximum efficacy after about one month of use. If medication is stopped, blood lipids will rise back to pre-treatment levels. This is because existing lipid-lowering drugs only correct abnormal lipid metabolism at a specific stage, such as affecting lipid absorption, inhibiting cholesterol synthesis, or promoting lipid breakdown. Once medication is stopped, the therapeutic effect on abnormal lipid metabolism disappears, and blood lipids will rise again. This is the rebound effect after stopping medication. Therefore, to effectively regulate blood lipids, long-term use of lipid-lowering medication is necessary.

Can health supplements regulate blood lipids?

Legitimate health supplements should have a lipid-regulating effect, but the effect is generally weak and they are expensive. If the blood lipid abnormality is not severe and you have the financial means, you can take some health supplements, but you should still consult a doctor and decide whether to add lipid-regulating medication based on their advice. In recent years, various media outlets have reported that deep-sea fish oil has a lipid-regulating effect, leading many patients to take it as their sole lipid-regulating medication. In reality, deep-sea fish oil does have only a weak lipid-regulating effect. The main active component is polyunsaturated fatty acids, primarily eicosapentaenoic acid (EPA), which only slightly lowers triglycerides. Therefore, deep-sea fish oil cannot be considered a lipid-regulating medication. Moreover, the quality of health supplements varies greatly; some products are not only ineffective but may even be harmful.

How to Increase HDL-C?

Although cholesterol is the primary target for lipid-lowering therapy in coronary heart disease (CHD), LDL-C is not the only risk factor. In other words, simply lowering LDL-C is not the only goal of lipid-lowering treatment. In fact, even after CHD patients achieve target LDL-C levels with statins, if LDL-C remains low (<1.04 mmol/L), atherosclerosis will continue to progress. Therefore, increasing HDL-C is a crucial aspect of CHD lipid-lowering treatment. Lifestyle modifications, including smoking cessation, a balanced diet, regular exercise, and weight control, are generally considered fundamental measures for increasing HDL-C. Medications that increase HDL-C include niacin and fibrates, which can be taken under the guidance of a doctor.

What exactly happened with the Silvastatin incident?

Silvastatin, also known as Bayeristan, is highly effective in lowering blood lipids, especially cholesterol, and is suitable for primary hypercholesterolemia, mixed hyperlipidemia, and hypertriglyceridemia. However, during clinical use, it was discovered that when this drug is used in combination with gemfibrozil, it can cause rhabdomyolysis, leading to kidney failure and even death. Rhabdomyolysis is a rare but potentially life-threatening adverse reaction. This incident of Silvastatin causing rhabdomyolysis caused a significant international stir, prompting the manufacturer to urgently recall the drug in August 2001. This event is known internationally as the Silvastatin incident.

Why do so many patients with dyslipidemia discontinue medication midway through treatment?

According to surveys, the discontinuation rate after 3 months of lipid-lowering therapy reaches 50%, and most patients discontinue medication after 6 months. The reasons are:

① Insufficient understanding of lipid-lowering therapy; patients believe that dyslipidemia is less dangerous than hypertension and does not require long-term treatment;

② Excessive worry about adverse reactions, leading to reluctance to take medication or discontinuation, especially after learning about the Baisiting incident, which easily caused patients' fear;

③ Patients have higher trust in health supplements than in statins;

④ The desire for immediate effects and subjective feelings from lipid-lowering drugs often leads patients to discontinue medication after lipid levels decrease or when the effect is not obvious.

Can dyslipidemia be cured?

This depends on the specific situation. Dyslipidemia is divided into secondary and primary types. Secondary dyslipidemia refers to dyslipidemia where the cause can be identified; while primary dyslipidemia refers to dyslipidemia where the cause is currently unknown. Primary dyslipidemia is more common clinically. The cause of primary dyslipidemia is unknown, requiring long-term medication control. Dyslipidemia recurs after medication is discontinued, and it cannot be cured. Common diseases causing secondary dyslipidemia include diabetes, hypothyroidism, liver disease, chronic renal failure, and nephrotic syndrome. Some medications (such as glucocorticoids, diuretics, and beta-blockers) can also cause drug-induced hyperlipidemia. For this type of dyslipidemia, lipid levels will return to normal after the primary disease is controlled. Therefore, it is inaccurate to say that dyslipidemia can be cured in general. Clinically, many patients have a high rate of discontinuing medication, possibly due to a misunderstanding of dyslipidemia, believing that medication for a period of time can cure the disease. This viewpoint should be changed. Treatment of primary dyslipidemia is a long-term process; therefore, a commitment to consistent treatment and lifelong medication is essential.