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Cholesterol may require drug therapy


My wife is 42 and has a cholesterol level of 270 even though she follows a cholesterol-lowering diet with great care. I am concerned because her doctor is reluctant to treat her with a medication to lower her cholesterol. Would you recommend drug treatment for her?

A: It is impossible to answer your specific question without more information, but some more general information on the treatment of a high cholesterol may be helpful.

The decision as to whether to use drug therapy in people with a high cholesterol is based on two considerations: the level of the atherogenic low density lipoprotein (LDL) cholesterol and the coronary risk status of the individual.

The guidelines for such decisions have undergone a recent change with the publication of the summary of a second report from the National Cholesterol Education program in June of this year. The previous guidelines recommended drug treatment for people at any age if their LDL cholesterol exceeded 190 milligrams per deciliters (mg/dl) despite an adequate dietary trial.

The new guidelines advise that drug therapy should be delayed in men under age 35 and in premenopausal women without other risk factors unless the LDL cholesterol is greater than 220 mg/dl. The LDL cholesterol is calculated by subtracting the HDL cholesterol and the triglycerides divided by 5 from the total cholesterol.

This calculation cannot be made for your wife, since the HDL cholesterol and triglyceride values were not provided, but with a cholesterol of 170 it is highly unlikely that her LDL cholesterol is greater than 220 mg/dl. And so drug treatment would not be hTC recommended under the new guidelines unless she has other risk factors. These include hypertension, current cigarette smoking, an HDL cholesterol less than 35 mg/dl, diabetes and a history of premature coronary disease in a parent or sibling.

The new guidelines also advocate more aggressive treatment for individuals considered to be at exceptional risk because they have one or more of the following conditions: coronary artery disease (angina, prior heart attack, angioplasty or coronary bypass surgery), stroke, poor blood supply to the legs, or diabetes.

Dr. Margolis is professor of medicine and biological chemistry at the Johns Hopkins School of Medicine.

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