#23-Tom Dayspring Part IV of V: statins, Zetia, PCSK9 inhibitors, niacin, cholesterol & the brain

Original release date: 10/18/2018
In this five-part series, Thomas Dayspring, M.D., FACP, FNLA, a world-renowned expert in lipidology, and one of Peter’s most important clinical mentors, shares his wealth of knowledge on the subject of lipids. In Part IV, Peter and Tom review the history and current use of drugs to prevent cardiovascular disease. They also discuss why some drugs appear to be more effective than others, an in-depth conversation about niacin, cholesterol and brain health, and the futility of using CKs (creatinine kinase) and liver function tests to identify adverse effects in statins, to name a few topics in this episode.
We discuss:
-Bile acid sequestrants and statins [2:00];
-Ezetimibe (Zetia) [15:00];
-PCSK9 inhibitors [27:30];
-Fibrates [41:00];
-Fish oil, DHA, and EPA [1:01:00];
-Niacin [1:05:15];
-PCSK9 inhibitors [1:23:45];
-Cholesterol, statins, and the brain [1:30:00];
-Elevated creatine kinase (CK) and liver function tests (LFTs) on statins [1:50:30]; and
-More.
Show notes page: peterattiamd.com/tomdayspring4/
About:
The Peter Attia Drive is a weekly, ultra-deep-dive podcast focusing on maximizing health, longevity, critical thinking…and a few other things. With over 10 million episodes downloaded, it features topics including fasting, ketosis, Alzheimer’s disease, cancer, mental health, and much more.
Peter is the founder of Attia Medical, PC, a medical practice with offices in San Diego and New York City, focusing on the applied science of longevity. The practice applies nutritional biochemistry, exercise physiology, sleep physiology, techniques to increase distress tolerance, lipidology, pharmacology, and four-system endocrinology to increase lifespan (delaying the onset of chronic disease), while simultaneously improving healthspan (quality of life).
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[@ellianaredick6817]

Amazing Drive Podcast! Tom Dayspring is a walking Lipid Encyclopedia! Some much information. A lot of promise of PCSK9 Inhibitors. Thanks Peter for sharing.

[@tesos2866]

I started a zedia monotherapy, I had a 41% drop in apo-b and a 30% reduction in LP(a)* I was very impressed as that was with zero side effects. *May be coincidental.

[@billytheweasel]

I’ve followed Dr Attia for a decade and so grateful it’s ridiculous.

[@aa-xn5hc]

Outstanding........!!

[@hidaven]

Peter, Tom is a big fan of Zetia. Seems to work the same way the old Welchol did. What are his thoughts on Bempodic Acid? Increased gout and gallstones but only 1%. They have a pill that combines the BA with Zetia for a potent cocktail. As a former Cardiovascular specialist, adjusting biomarkers go only so far…..Try limiting your calories and get down to a lean weight and watch what happens to all of your lipid parameters. Humans didn’t evolve on 3 big meals a day. Lastly, the PCSK9i’s have a small but interesting correlation to some neurological issues from some of the recent data. Keep up the good work.

[@Vidyut_Gore]

How would ezetimibe impact fats we want absorbed? Omega-3s, fat soluble nutrients, etc?

[@motomatta1]

Excellent Podcast 🙂👍

[@ayan0834]

Peter, since you rigorously monitor biomarkers in your patients, would you be able to shed any light on whether you have seen any changes in serum testosterone in your male patients after starting a PCSK9 inhibitor? Specifically, I would be interested in cases where patients are intolerant to statins, and PCSK9 monotherapy is being employed. While PCSK9 inhibitors don't hinder cholesterol synthesis (and thus should have less impact than statins), the question remains as to whether (and how much) the gonads depend on LDL-receptor mediated cholesterol entry, as opposed to de novo production. The only proper trial I seemed to find, with evolocumab, did show some lowering, specifically at higher baseline testosterone levels, but I don't think enough attention has been given to this.

[@fpypnts]

They address this pretty clearly in here. Cells will make all the cholesterol they need independent of LDLp. If statins reducing LDLp doesn’t affect sex hormone synthesis then the LDLp then why should PCSK9?

[@Vidyut_Gore]

I don't know why cardiologists can't figure this out on their own. I heard Dr. Tom on Dr Brad's channel, mostly because my lipid levels were high, and instantly decided to try Ezetimibe first. He explains so well, it just makes sense. If the doctor won't agree, I'll show him the video.

[@vladstefanovic5737]

I'm so curious how all this applies to a not "normal" person. Specifically, a liver transplant recepient who is on an immunosuppressant which is also an mTOR inhibitor which is wreaking havoc on the lipids.... I have searched but I haven't been able to find a good source of info regarding the mechanism of how and why this medication does what it does therefore I'm clueless on which tools are the most appropriate to address the situation.

[@gerardnc]

Dr. Attia, neither you or Dr. Dayspring talked about niacin being effective in lowering LP (a). Do the side effects of niacin outweigh the benefits of lowering LP (a) levels?

[@andreeanitescu9026]

They did, please watch part V of the interview, that's where they address it.

[@GerardCantor]

@@andreeanitescu9026 their discussion on niacin mostly revolved about its use to lower ApoB and raising HDL and whether it’s effective in lowering heart events. But high LPA (a) has no medication to lower it except for niacin, so I wonder whether their conclusions about its use for lowering LP (a) are also mostly negative given the many side effects.

[@sabby123456789]

So if you are a hyper-absorber of cholesterol and phytosterols and are a hyper-responder to saturated fat, then what can you eat? Do you have to eat mostly lean meat with olive oiled salads?

[@orchidmuse]

He recommends in other interviews to try a diet for about 8 weeks and then get your apoB retested. And if doesn't help, change it and try a new one. He mentions Mediterranean diet as an example. Or take a drug and also monitor.

[@ApoBeef]

What's that blood marker that Dayspring was talking about with respect to cognitive function? Demenstrol or something?

[@nanduthalange7736]

Desmesterol

[@Connie7881]

Tom won’t let you talk😢

[@BrunchwiththeBradleys]

I know. Loves the sound of his own voice. I’m Googling the speaker to listen to him Without his constant interruption and interference

[@LynnFishmanMeditation]

Excellent podcast. As we all know, memory loss and confusion have been reported with statins and a regular physician usually won't test for any markers that could reflect lack of cholesterol in the brain. Not denying however, the extraordinary benefit that statins play in the prevention of vascular complications and arteriosclerosis.

[@bigcat9977]

In an address to students at Harvard Medical School, Dean Sidney Burwell said, "Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don't know which half is which." Dr. Attia don't be so sure about your believes in statins and don't call others that disagree with you "statin deniers" or members of Internet cult. The lipid hypothesis, after so many decades of debates and studies, is still only a hypothesis, isn't it? IMO statins had been way overprescribed to say the least. I was on statins for a few years. Had perfect cholesterol numbers but felt lousy and developed chronic diseases. Each time I raised concerns about statins to my doctors I only got dismissive responses... I finally wised up a year ago and stopped all prescriptions. Started LCHF, OMAD and exercise. Reversed my prediabetes, improved cognitive functions, got bp back to normal, got stronger, and even looking younger... My LDL spiked but all other biomarkers are normal. (I'm a LMHR.) I'm feeling better and stronger now than I was 2-3 decades ago. I remain open-minded on LDL, but not concerned about it. It's all about "healthspan" instead of "lifespan", isn't it? I don't know if statins would lengthen my lifespan, but I definitely know it shorten my healthspan.

[@gerardnc]

I hear what you're saying but I think you're missing the nuance of this podcast. Dr. Attia or Dr. Dayspring are not your typical cardiologists who simply try to lower LDL blindly by prescribing a high dose statin. Listen to this podcast. They are going into lots of details about specific blood markers that with the help of different medications, are able to result in better outcomes. Even in cases where enough blind randomized clinical trials are missing, they see enough benefit in patients that would lead them to prescribe some combination of meds (ezetimibe, niacin, statin, PCSK9 inhibitors). Both things can be true: statins are overprescribed but they also have benefit. The problem is that most mainstream cardiologists only measure LDL and does not pay attention to oxidized particles, ApoB, LP (a), plant sterols, etc. then you could very well be a patient who's prescribed a statin, without having had these other issues addressed which would hardly be of benefit. And yes, LDL in an of itself is not a risk factor per se, but lowering some of these aforementioned markers could very well save your life. LCHF, even OMAD have also shown great results, and we know that this would lower your triglyceride levels, which is great, but I hope you have a good enough cardiologist to measure a whole lot more than your LDL, because the devil (i.e. heart disease) is in the details when it comes to lipidology.

[@jerseyjim9092]

Tell me why some people have high LDL their entire life and don't get CAD and why others who have low LDL their entire life do get CAD.

[@evanrosenlieb8819]

I'm surprised fibrates didn't come up... aren't fibrates really old and weren't they used to lower cholesterol before statins? Never mind they came up.

[@drnelogals]

Tom won’t let you speak or interject. Bulldozer!!

[@dinomiles7999]

Conditioned EGO mind controll is a scary thing .

[@peouspaul1258]

America encourage people to eat lot of non veg and milk products .. once people sick , only rich survive..

[@greendeane1]

Oh wow! My cardio-vascular system is made great with statins and my brain mindless.... Frankly I'd rather die with my brain in tact then live 15 years without a brain but a good heart.

[@bigbobabc123]

True zetia or pcsk9 inhibitors

[@dinomiles7999]

Sorry Peter , it's a new world . The train has left the station , and your NOT on it . Love you buddy . SO SAD .

[@evanrosenlieb8819]

... what?