What Should Your Cholesterol Be?

It is quite amusing to read such terms as "Target" and "Fire and Forget" in medical journals, especially in such a prestigious one as The Lancet. The last time I heard and used terms like these was in summer camp with the Vermont Army National Guard during practice firing of our tank guns.
"Treat to target" was a lot like our wire-guided rockets that were manually controlled all the way. "Fire and forget" meant you just pulled the trigger and the missile would find the target even if the target was unseen.

The medical community is now using such terms to describe the proper dosing of statin drugs.  For many years the medical ‘talking heads' have endorsed "treat to target" as the most desirable approach.

You may recall that years ago a total cholesterol of 240 was not considered anything to worry about - anything under 300 was no big deal. Then this upper limit of normal was reduced progressively to 240, then 220, then 200 and I no longer am certain of the lower value, it keeps changing so often.

Obviously if you place the target level low enough everyone must fall into the need to be treated group.
With these new levels, if 10mg or 20 mg of a statin fails to produce the desired effect you up the ante to 40, 60 or even 80 mg until the target is reached, hence "treat to target".

Mind you these new figures all are based on drug company marketing promos or sponsored research demonstrating the absolute imperative of getting as many people as possible under the protective statin umbrella. The fact that whatever good these statins were doing was based upon the powerful anti-inflammatory effect of statin drugs and not cholesterol reduction was kept well hidden, for why spoil a very good thing?

If you have familial hypercholesterolemia, a genetic disorder, we are talking of an entirely different condition - a disease state that must be treated.

The studies about the unexpected adverse reactions of statins have now emerged sufficiently to concern even the most satisfied statin prescriber. The result has been a growing shift to the "fire and forget" mode of statin dosing. With this method a doctor prescribes a low- to moderate-dose statin to those at risk for coronary artery disease, finding that this is a better public health strategy than treatment based purely upon LDL cholesterol target levels.

In other words some in the medical community are offering a relatively low dose of statins to those at risk but achieving far greater public health benefit because of far fewer adverse reactions.

I see this move as the beginning of the proper way to treat atherosclerosis. I say beginning only, because we first have to establish for each brand of statins the dose least likely to cause mevalonate blockade while still retaining the anti-inflammatory effect.

In the zeal to reduce cholesterol not only have we inhibited the synthesis of cholesterol carried in this pathway but we have blocked the synthesis of other mevalonate pathway functions such as CoQ10 and dolichols, and therein caused our adverse reactions. This is warfare's collateral damage - another military term that I will interject because it fits so well.

Duane Graveline MD MPH
Former USAF Flight Surgeon
Former NASA Astronaut
Retired Family Doctor

Hayward, R. Optimizing statin treatment for primary prevention of coronary artery disease. Ann Intern Med. 152:69-77, 2010
Shepherd J. Resource management in prevention of coronary heart disease: Optimising prescription of lipid-lowering drugs. Lancet;359:2271-3

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