Friday, 5 April 2019

Farewell to the fasting cholesterol test

Over the last year, the general public has been inundated with a steady stream of reports about the dangers of opiates — pain medicines like codeine, Percocet, and OxyContin. The harm in terms of ruined lives and death from illicit drugs such as heroin is not news. But what is new, and concerning, are the risks of prescription pain medicines — those doctors prescribe for pain due to a range of causes, including musculoskeletal problems like low back pain.
The history of using opiates for chronic pain

Back pain isn’t a new problem either, but the history of how doctors have treated it is probably new to many. A “cliff notes” version of what changed goes something like this. Studies showed that doctors weren’t adequately treating the pain of people with advanced cancer. Research also showed that pain medicines such as opiates improved quality of life for these terminally ill patients. This realization led to recommendations that doctors monitor pain as they would any other vital sign (like temperature or blood pressure) for all their patients — and that all types of pain receive aggressive treatment, including long-term (chronic) pain, such as low back pain. At the same time, drug companies promoted new formulations of opioid medications with longer duration of activity that made it easier for patients to take on a regular basis.

The problem was that this fundamental change in practice was really devoid of any proof that it would help people better manage pain and minimize its effect on their lives. Prior reviews of the medical literature have documented that there is little evidence supporting the use of opiates for chronic low back pain. The modest benefits seen were with short-term use. The practice of using these medicines for long periods of time has not been carefully evaluated. Few risks were seen in these short-term studies, but tolerance to the effects of the medicine, side effects and dependence/addiction have become clearer with longer use.

A recent study published in JAMA Internal Medicine adds to this knowledge. Dr. Abdel Shaheed and colleagues performed an updated literature review, and their conclusions reinforce that only short-term benefits have been proven and the amount of that benefit is modest. Moreover, they examined the doses of pain medicines used in these studies and found that the pain relief people actually experienced was not that great.
Opiates for chronic low back pain carry big risks with uncertain benefits

This and prior studies clearly show that the leap to widespread use of opiates for non-cancer pain was premature. We didn’t know the long-term benefits and risks. We still don’t know the benefits, but this dramatic increase in use of pain medicines hasn’t helped people return to their previous level of activity, and rates of disability haven’t gone down. What is becoming clear are the risks, specifically rates of addiction, overdoses, and the rise of deaths attributed to prescription opiates. And people who have become addicted to their prescribed pain medicines often switch to heroin, which is cheaper and more readily available.

Now this doesn’t mean that we should stop treating pain. For many, the pain is real, chronic, disabling, and they need help managing it. And it doesn’t mean that everyone prescribed opiates becomes addicted. Nor does it suggest that opiate medicines have no benefits at all. But what it should do is give all of us pause. The bottom line is that simply taking a pill (or a handful of pills) doesn’t fix low back pain — and can lead to a whole lot of trouble.
What you can do for back pain

Fortunately, there is growing evidence for treatments that can help with chronic low-back pain, but they aren’t simple fixes in the form of pills, shots or surgery. Instead, treatments should focus on getting back pain sufferers active again and learning to manage, not cure, the pain. A range of therapies including exercise, education about how to care for your back, yoga, and mind-body techniques have been shown to help control back pain. Over the last year, the general public has been inundated with a steady stream of reports about the dangers of opiates — pain medicines like codeine, Percocet, and OxyContin. The harm in terms of ruined lives and death from illicit drugs such as heroin is not news. But what is new, and concerning, are the risks of prescription pain medicines — those doctors prescribe for pain due to a range of causes, including musculoskeletal problems like low back pain.
The history of using opiates for chronic pain

Back pain isn’t a new problem either, but the history of how doctors have treated it is probably new to many. A “cliff notes” version of what changed goes something like this. Studies showed that doctors weren’t adequately treating the pain of people with advanced cancer. Research also showed that pain medicines such as opiates improved quality of life for these terminally ill patients. This realization led to recommendations that doctors monitor pain as they would any other vital sign (like temperature or blood pressure) for all their patients — and that all types of pain receive aggressive treatment, including long-term (chronic) pain, such as low back pain. At the same time, drug companies promoted new formulations of opioid medications with longer duration of activity that made it easier for patients to take on a regular basis.

The problem was that this fundamental change in practice was really devoid of any proof that it would help people better manage pain and minimize its effect on their lives. Prior reviews of the medical literature have documented that there is little evidence supporting the use of opiates for chronic low back pain. The modest benefits seen were with short-term use. The practice of using these medicines for long periods of time has not been carefully evaluated. Few risks were seen in these short-term studies, but tolerance to the effects of the medicine, side effects and dependence/addiction have become clearer with longer use.

A recent study published in JAMA Internal Medicine adds to this knowledge. Dr. Abdel Shaheed and colleagues performed an updated literature review, and their conclusions reinforce that only short-term benefits have been proven and the amount of that benefit is modest. Moreover, they examined the doses of pain medicines used in these studies and found that the pain relief people actually experienced was not that great.
Opiates for chronic low back pain carry big risks with uncertain benefits

This and prior studies clearly show that the leap to widespread use of opiates for non-cancer pain was premature. We didn’t know the long-term benefits and risks. We still don’t know the benefits, but this dramatic increase in use of pain medicines hasn’t helped people return to their previous level of activity, and rates of disability haven’t gone down. What is becoming clear are the risks, specifically rates of addiction, overdoses, and the rise of deaths attributed to prescription opiates. And people who have become addicted to their prescribed pain medicines often switch to heroin, which is cheaper and more readily available.

Now this doesn’t mean that we should stop treating pain. For many, the pain is real, chronic, disabling, and they need help managing it. And it doesn’t mean that everyone prescribed opiates becomes addicted. Nor does it suggest that opiate medicines have no benefits at all. But what it should do is give all of us pause. The bottom line is that simply taking a pill (or a handful of pills) doesn’t fix low back pain — and can lead to a whole lot of trouble.
What you can do for back pain

Fortunately, there is growing evidence for treatments that can help with chronic low-back pain, but they aren’t simple fixes in the form of pills, shots or surgery. Instead, treatments should focus on getting back pain sufferers active again and learning to manage, not cure, the pain. A range of therapies including exercise, education about how to care for your back, yoga, and mind-body techniques have been shown to help control back pain.

So what do I tell my patients? For those with chronic back pain who aren’t on opiates, steer clear. For those who are already take them, you can’t go cold turkey. Your body has adjusted to these medicines and stopping them abruptly is a bad idea. With help, people on opiate pain relievers can try to wean themselves off these medicines gradually and replace them with other treatments. This isn’t easy, but for many people it starts a long process of regaining control over the pain that has taken over their lives and can help them avoid the terrible consequences of opiate addiction. At a recent meeting I offered a visitor lunch which she declined with obvious regret. She was hungry, and it was noon. But she was headed to her annual physical, and eating beforehand would mean returning another morning for a fasting cholesterol level. Most of us can relate to her annoyance, but thankfully this may soon be a thing of the past.

Doctors have traditionally ordered cholesterol tests to be drawn after an overnight fast. But this requirement causes a significant burden on both sides of the health care equation. Most people hate to fast. Skipping meals is particularly difficult for active people, people with diabetes, and children. Yet coming back for another visit is even more of a hassle, so many people just don’t bother. And it has been a drain for doctors, too, resulting in repeat test orders, phone calls, and patient visits.

International guidelines published last month in the European Heart Journal became the latest official recommendation against routine fasting for cholesterol tests. These guidelines defend what many health care systems and many doctors (including me) have been practicing for several years already. They should be met with universal acceptance, even if takes a while. There are several scientific reasons supporting this change.
The history behind fasting cholesterol tests

When doctors test for cholesterol, we almost always order a group of tests called a lipid panel (lipids are fat-containing molecules). This panel typically includes four separate measures:

    Total cholesterol concentration.
    Low-density lipoprotein* (LDL) – cholesterol, often called the “bad” cholesterol. The amount of LDL in your blood strongly predicts your risk of cardiovascular disease, as higher levels are associated with development of plaque in the arteries.
    High-density lipoprotein (HDL) – cholesterol, often called “good cholesterol” because higher levels protect against heart disease.
    Triglycerides (a different type of lipid molecule). High levels of triglycerides are also associated with vascular disease, although this relationship isn’t as well defined.

*Lipoproteins are the “packages” that transport cholesterol in the bloodstream.

Lipids have traditionally been drawn after a fast for two main reasons. The first was to minimize variation, since eating can affect some lipid levels. The second was to produce a better calculation of LDL-cholesterol, which is often derived from an equation thought to provide highly distorted results after eating. However, more recent studies have largely negated these concerns.

Scientists now agree that eating has only slight, clinically insignificant effects on three parts of the lipid profile: total cholesterol, and both HDL- and LDL-cholesterol. Food does raise triglyceride levels for several hours, usually to a modest degree. After a high fat meal these increases can be striking. Therefore, a doctor may still order a fasting test of triglycerides if non-fasting values are significantly elevated.

Perhaps more important, large-scale analyses have shown that non-fasting lipids don’t weaken the connection between cholesterol levels and harmful events like heart attack and stroke. In fact, post-meal measures are thought to strengthen the ability of lipid levels to predict cardiovascular risk. This observation may stem from the fact that most people eat several meals plus snacks during the day. That means we spend most of our time in a “fed” state, not a fasting state. So lipid levels after eating may best reflect our normal physiology.
An end to the dreaded overnight fast?

Guidelines for lipid panels have evolved over the past decade, supported by evidence from studies involving hundreds of thousands of people. Most recommendations now support non-fasting cholesterol tests for routine testing. (You can find a summary of these recommendations here.)

Some fasting lipids tests will remain necessary, especially in people with very high triglycerides. And some people will still need to fast for blood sugar levels, although an alternative test for diabetes (hemoglobin A1c) has replaced much of this testing. But for most, including those having routine cholesterol tests to weigh cardiovascular risk and for those taking drug therapy, this news is good news.

So ask your doctor if you really need to skip breakfast before your next blood draw. Traditions die hard, but both science and convenience may ultimately steer this one to its end. This is one change doctors and patients should celebrate together.

So what do I tell my patients? For those with chronic back pain who aren’t on opiates, steer clear. For those who are already take them, you can’t go cold turkey. Your body has adjusted to these medicines and stopping them abruptly is a bad idea. With help, people on opiate pain relievers can try to wean themselves off these medicines gradually and replace them with other treatments. This isn’t easy, but for many people it starts a long process of regaining control over the pain that has taken over their lives and can help them avoid the terrible consequences of opiate addiction.

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